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"comment": "when you interpret it as each fingertip = 1g :(",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "1 x 2 = 2g used daily\n\n2g x 14 = 28g used in 2 weeks\n\n28 x 250 = 7000 micrograms of betamethasone = 7mg",
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"question": "A 36-year-old patient has eczema that affects her hands. She uses 2 finger-tip units per application (one finger-tip for each hand), which is equivalent to 1g of Betnovate cream. Betnovate cream contains 250 micrograms per 1 gram of the active ingredient, betamethasone.\n\nIf she is applying Betnovate cream twice daily, how many mg of betamethasone will she use in 2 weeks? ",
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"comment": "this is an insane question ngl",
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"comment": "no cos like how are we supposed to do it in that much time ",
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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 10mg/hour: 10mg/hour x 0.5 hours = 5mg\n- 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: 5mg + 10mg + 20mg + 20mg = 55mg\n\n10mg given for 30 minutes (0.5 hours).\n20mg given for 30 minutes (0.5 hours).\n40mg given for 30 minutes (0.5 hours).\n80mg given for 15 minutes (0.25 hours).\n\n1.75 hours total. 55/1.75 = 31.4285714\n\nTo one decimal place = 31.4mg/hr",
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"question": " \n\nCase Presentation:\n\nA 34-year-old patient with hypertension in pregnancy is prescribed labetalol by intravenous infusion.\n\nShe was initially given 10mg/hour, which was increased to 20mg/hour after 30 minutes, this was continued for 30 minutes and then increased to 40mg/hour. After another 30 minutes this was finally increased to 80mg/hour.\n\nThis continued for 15 minutes, after which the response was satisfactory and the infusion was stopped.\n\nWhat is the average hourly rate at which this infusion has been given? Give your answer to one decimal place.",
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173,467,955 | false | 53 | null | 6,495,250 | null | false | [] | null | 10,151 | {
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"comment": "Why is subcut dose divided by 2?",
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"comment": "Good qn\n",
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"comment": "Subcutaneous morphine is twice as strong as oral morphine (so you only need half as much of it)",
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"comment": "It's on the BNF under palliative care pain prescribing. There's a whole table to convert doses",
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"comment": "This question is a bit pointless if you're not giving them the dose of the breakthrough morphine",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "4 x 15 = 60mg needed as a baseline\n\n60/6 = 10mg x 2 = 20mg needed as a breakthrough dose\n\n60 + 20 = 80mg needed orally to manage pain.\n\n80/2 = 40mg needed subcutaneously to manage pain.",
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"question": " \n\nCase Presentation:\n\nA 86-year-old gentleman is currently on the care of the elderly ward. His regular medicines are listed below. Weight 60kg.\n\n**PH** Metastatic prostate cancer, Osteoarthritis, Hypertension, Hypercholesterolaemia\n\n**DH** Morphine 15mg PO QDS, ramipril 5mg PO OD, Atorvastatin 20mg PO OD\n\nIn addition to his regular morphine, this patient requires **TWO** breakthrough doses of morphine throughout the day. This manages his pain.\n\nHe has been having difficulty swallowing and the decision has been made to switch the formulation of his medication from oral to another formulation that doesn't require swallowing.\n\nWhat is the total dose of morphine required daily to manage this patient's pain if it is given subcutaneously?",
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"explanation": "Total daily dose = 30 kg x 30 mg = 900 mg\nIn two divided doses = 900 / 2 = 450 mg per dose\nVolume of solution for each dose = 450 mg / (5 mL/ 200 mg) = 11.25 mL",
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"question": "A 9-year-old boy is brought to his Neurology outpatients appointment by his father for review of his epilepsy medication. He is commenced on sodium valproate 30 mg/kg maintenance PO in two divided doses. He weighs 30 kg.\n\n\nSodium valproate is available as a 200 mg/5 mL oral solution. What volume (mL) of sodium valproate oral solution should the patient be given for each dose? Round your answer to 2 decimal places.",
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"explanation": "Bisoprolol does not commonly cause bleeding",
"id": "34196",
"label": "b",
"name": "Bisoprolol fumarate 5mg PO daily",
"picture": null,
"votes": 8
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"__typename": "QuestionChoice",
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"explanation": "Ramipril does not commonly cause bleeding",
"id": "34198",
"label": "d",
"name": "Ramipril 2.5mg PO daily",
"picture": null,
"votes": 26
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"id": "34197",
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"name": "Digoxin 125 micrograms PO daily",
"picture": null,
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"id": "34199",
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"name": "Amlodipine 10mg PO daily",
"picture": null,
"votes": 5
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"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,
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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 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.",
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173,467,958 | false | 56 | null | 6,495,250 | null | false | [] | null | 6,853 | {
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"__typename": "QuestionChoice",
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"explanation": "Atorvastatin does not commonly cause renal stones",
"id": "34212",
"label": "c",
"name": "Atorvastatin 10mg PO OD",
"picture": null,
"votes": 259
},
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"__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,
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"explanation": "Dalteparin does not commonly cause renal stones",
"id": "34213",
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"picture": null,
"votes": 134
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"__typename": "QuestionChoice",
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"explanation": "Tamsulosin does not commonly cause renal stones",
"id": "34214",
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"name": "Tamsulosin 400 micrograms PO OD",
"picture": null,
"votes": 503
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"__typename": "QuestionChoice",
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"explanation": "Bisoprolol does not commonly cause renal stones",
"id": "34211",
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"name": "Bisoprolol 10mg PO OD",
"picture": null,
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"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'?)",
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"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 :)",
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"comment": "Yes sir, assumed knowledge is what they call it :(\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 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"
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173,467,959 | false | 57 | null | 6,495,250 | null | false | [] | null | 6,855 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Daleparin does not commonly cause orthostatic hypotension",
"id": "34224",
"label": "e",
"name": "Dalteparin sodium 2500 units SC OD",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine can cause dizziness but is not known to commonly cause orthostatic hypotension",
"id": "34223",
"label": "d",
"name": "Amlodipine 5mg PO daily",
"picture": null,
"votes": 741
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Tamsulosin, an alpha1-adrenoreceptor blocker is known to cause postural hypotension due to the inhibition of alpha-1 receptors, leading to vascular smooth muscle relaxation and vasodilation the loss of reflex vasoconstriction upon standing",
"id": "34220",
"label": "a",
"name": "Tamsulosin 400 micrograms PO OD",
"picture": null,
"votes": 3994
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Carbamazepine does not commonly cause orthostatic hypotension",
"id": "34222",
"label": "c",
"name": "Carbamazepine",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-careldopa does not commonly cause orthostatic hypotension",
"id": "34221",
"label": "b",
"name": "Co-careldopa 25/100 TDS PO",
"picture": null,
"votes": 285
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "The question says he has syncope. Syncope is common with bisoprolol.\nOrthostatic hypotension is listed as not common for tamsulosin.",
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"comment": "I'm guessing because the reason for his syncope is due to orthostatic hypotension and not b-blocker related (e.g., bradycardia)",
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"comment": "Why isn't bisoprolol an acceptable answer? Postural hypotension is listed as an uncommon side effect for both bisoprolol and tamsulosin.",
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"comment": "I think because BNF has a whole caution section for tamsulosin about postural hypotension which bisoprolol doesn't ? ",
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"comment": " postural hypotension is listed in the uncommon side effect section for both bisoprolol and tamsulosin. how are we meant to choose which one",
"createdAt": 1706727945,
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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": "74",
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"typeId": 5
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"question": "Case Presentation: An 85-year-old man is transferred to the care of the elderly ward following an episode of syncope. PMH Hypertension, BPH, Epilepsy, Parkinson disease. DH His current regular medicines are listed (below).\r\n\r\n\nOn examination\nLying BP 120/85mmHg, HR 80/min; standing BP 90/70mmHg, HR 100/min\n\nQuestion: Select the prescription that is most likely to contribute to his orthostatic hypotension.\n",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,467,960 | false | 58 | null | 6,495,250 | null | false | [] | null | 10,077 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is suffering from benzodiazepine toxicity. Benzodiazepine toxicity leads to muscarinic effects such as ataxia, dysarthria and nystagmus and in severe cases, respiratory depression which can be fatal.",
"id": "50146",
"label": "a",
"name": "Diazepam",
"picture": null,
"votes": 2373
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "MDMA is a stimulant recreational drug known as 'ecstasy'. MDMA toxicity leads to confusion, coma, convulsions, ventricular arrhythmias, hyperthermia, rhabdomyolysis, acute renal failure, acute hepatitis, disseminated intravascular coagulation, adult respiratory distress syndrome, hyperreflexia, hypotension and intracerebral haemorrhage. Self-induced water intoxication can also lead to hyponatraemia.",
"id": "50148",
"label": "c",
"name": "Methylenedioxymethamphetamine (MDMA)",
"picture": null,
"votes": 627
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amphetamines are stimulant recreational drugs. Toxicity leads to signs such as wakefulness, excessive activity, paranoia, hallucinations, hypertension and in more severe cases; exhaustion, convulsions, hyperthermia, and coma.",
"id": "50150",
"label": "e",
"name": "Amphetamine",
"picture": null,
"votes": 345
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oxycodone is an opioid that is sometimes used recreationally. Opioid overdose has a similar clinical presentation to this patient in the form of respiratory depression and drowsiness. However, opioid toxicity causes different eye signs, most notably, constricted pinpoint pupils.",
"id": "50147",
"label": "b",
"name": "Oxycodone",
"picture": null,
"votes": 117
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cocaine is a stimulant drug used recreationally. Cocaine toxicity can lead to effects signs such as agitation, dilated pupils, tachycardia, hypertension, hallucinations, hyperthermia, hypertonia, and hyperreflexia. In severe cases, cocaine can cause myocardial infarction and arrhythmias.",
"id": "50149",
"label": "d",
"name": "Cocaine",
"picture": null,
"votes": 98
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "who's doing diazepam as a recreational drug ",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Benzodiazepine toxicity",
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"question": "Case Presentation: A 21-year-old female patient is brought to A&E drowsy and confused. Her friend reports that she has been taking recreational drugs. \n\n\n**PMH**\nNone\n\n**On examination**\n* Chest: clear, RR 12\n* HS: S1 S2 + no added sounds\n* Cranial Nerves: Nystagmus and dysarthria. Pupils are equal and reactive to light, normal size.\n\n**Investigation**\n\nRoutine blood tests are normal.\n\nQuestion: Which recreational drug is most likely to have caused these clinical signs?",
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173,467,961 | false | 59 | null | 6,495,250 | null | false | [] | null | 10,080 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly interact with morphine.",
"id": "50162",
"label": "b",
"name": "Atorvastatin 20mg PO OD",
"picture": null,
"votes": 41
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salmeterol does not commonly interact with morphine.",
"id": "50163",
"label": "c",
"name": "Salmeterol 50micrograms INH BD",
"picture": null,
"votes": 75
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tiotropium does not commonly interact with morphine.",
"id": "50164",
"label": "d",
"name": "Tiotropium 5micrograms INH OD",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
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"explanation": "Paracetamol does not commonly interact with morphine.",
"id": "50165",
"label": "e",
"name": "Paracetamol 1g PO QDS",
"picture": null,
"votes": 79
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is experiencing opioid toxicity. Tranylcypromine is a monoamine oxidase B inhibitor that is used to treat major depressive disorder. It has been shown to potentially increase the risk of opioid toxicity if taken alongside morphine.",
"id": "50161",
"label": "a",
"name": "Tranylcypromine 10mg PO OD",
"picture": null,
"votes": 3183
}
],
"comments": [],
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 62-year-old gentleman has recently undergone surgery for a broken neck of femur which was treated with a total hip replacement. He has been managing his post-operative pain with morphine. His regular medicines are listed (below). Weight 85kg.\n\n\n\n\n **PH** Depression, COPD, Hypercholesterolaemia, Ethanol excess\n\n\n **DH** Tranylcypromine 10mg PO OD, Atorvastatin 20mg PO OD, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH OD, Paracetamol 1g PO QDS\n\n\n **On examination**\nBP 109/68mmHg, HR 88, RR 4\n\n\nNeurological exam: Difficult to rouse the patient. Pupils appear small.\n\n\n **Investigation**\n\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.24|7.35 - 7.45|\n|PaO₂|6.0 kPa|11 - 15|\n|PaCO₂|9.4kPa|4.6 - 6.4|\n|Bicarbonate|18 mmol/L|22 - 30|\n\n\n\nQuestion: Select the medication that is most likely to have contributed to this patient's clinical condition.",
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"a"
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173,467,962 | false | 60 | null | 6,495,250 | null | false | [] | null | 10,131 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause hypercalcaemia.",
"id": "50388",
"label": "e",
"name": "Paracetamol 1g PO QDS",
"picture": null,
"votes": 3
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"__typename": "QuestionChoice",
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"explanation": "Amlodipine does not commonly cause hypercalcaemia. In very rare cases it has been found to cause hypocalcaemia.",
"id": "50386",
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"name": "Amlodipine 10mg PO OD",
"picture": null,
"votes": 126
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"answer": false,
"explanation": "Atorvastatin does not commonly cause hypercalcaemia.",
"id": "50387",
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"picture": null,
"votes": 15
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"__typename": "QuestionChoice",
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"explanation": "Indapamide is a thiazide-like diuretic. Thiazide-like diuretics work via increasing the availability of Na<sup>+</sup> in the urine, water then follows this and reduces the blood pressure. One way they do this is by increasing calcium reabsorption across the nephron in exchange for sodium - this in turn results in hypercalcaemia.",
"id": "50384",
"label": "a",
"name": "Indapamide 2.5mg PO OD",
"picture": null,
"votes": 3014
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"__typename": "QuestionChoice",
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"explanation": "Ramipril does not commonly cause hypercalcaemia.",
"id": "50385",
"label": "b",
"name": "Ramipril 10mg PO OD",
"picture": null,
"votes": 69
}
],
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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 72-year-old gentleman attends his GP for his blood results. His regular medicines are listed (below).\n\n\n\n\n **PH** Hypertension, Hypercholesterolaemia\n\n\n **DH** Atorvastatin 20mg PO OD, Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD, Paracetamol 1g PO QDS\n\n\n **On examination**\nBP 148/90mmHg, HR 84, RR 12, Weight 70kg\n\n\n **Investigation**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|136 mmol/L|135 - 145|\n|Potassium|4.1 mmol/L|3.5 - 5.3|\n|Urea|6.0 mmol/L|2.5 - 7.8|\n|Creatinine|100 µmol/L|60 - 120|\n|Calcium|3.0 mmol/L|2.2 - 2.6|\n|eGFR|70 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion: Select the medication that is most likely to have contributed to the abnormality in his blood results.",
"sbaAnswer": [
"a"
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"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "why isn't prednisolone right? he already has salbutamol prescribed, so isn't the assumption that he has already tried salbutamol?",
"createdAt": 1706198775,
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"comment": "Here he has salbutamol prescribed but as an inhaler for at home use, they would need to prescribe it again in the nebulised form as the dose is different. You're right that prednisolone would be used afterwards ( but it wouldn't be once off duration which is the clue)",
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"explanation": "# Summary\n \n\nAcute exacerbations of asthma in children are primarily triggered by allergens such as dust, pollution, animal hair, or smoke, leading to a type 1 (IgE-mediated) hypersensitivity reaction. This triggers bronchoconstriction and bronchial oedema. Signs of a severe episode may include respiratory distress, tachycardia, and significantly reduced peak expiratory flow rate. Key differentials include pneumothorax, anaphylaxis, foreign body inhalation, and cardiac arrhythmia. Investigations involve a stepwise approach to managing acute exacerbations according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, including the use of high-flow oxygen, inhaled and intravenous salbutamol, and steroids.\n \n\n# Definition\n \n\nAcute exacerbations of asthma in children are episodes where symptoms of asthma, a chronic inflammatory disease of the airways, are significantly intensified. This is typically due to triggers such as exposure to certain allergens, leading to a type 1 (IgE-mediated) hypersensitivity reaction, which results in bronchoconstriction and bronchial oedema.\n \n\n# Epidemiology\n \n\n - Asthma is a common condition, affecting millions of children globally.\n - Asthma can start at any age, but it most commonly begins during childhood.\n - Asthma exacerbations are among the most common reasons for hospitalisation in children.\n \n\n# Aetiology\n \n\nAcute exacerbations of asthma in children can be triggered by a variety of factors including:\n \n\n - Allergens: Dust, pollution, animal hair, smoke\n - Respiratory infections: Viruses such as the common cold\n - Exercise: Especially in cold weather\n - Emotional stress: This can lead to hyperventilation and symptoms of an asthma attack.\n\n \nRisk factors for severe acute asthma include:\n\n- Background of severe asthma (previous near-fatal asthma, or admissions to hospital/PICU)\n- Exposure to second-hand smoke, air pollution or pollen \n- Inadequately controlled asthma \n \n\n# Signs and Symptoms\n \n \n## Features of moderate acute asthma \n\n- Peak flow >50% predicted \n- Tachypnoea but respiratory rate less than 40/minute if 1-5 years old or less than 30/minute if over 5 years \n- Tachycardia but <140/minute if 1-5 years old or <125 if over 5 years \n- SpO2 >2%\n- The child is still able to speak in complete sentences \n\n## Features of acute severe asthma\n \n\n - Respiratory distress: use of accessory muscles of respiration, breathlessness resulting in an inability to complete sentences, tachypnoea with a respiratory rate > 30/min if over 5yrs, > 40 if under 5yrs\n - Heart rate > 125/min if over 5yrs, > 140/min if under 5yrs\n - Peak expiratory flow rate 33-50% of predicted\n \n\n## Features of life-threatening asthma \n \n\n - Peak expiratory flow rate <33% predicted\n - Oxygen saturations <92%\n - Silent chest on auscultation\n - Weak or no respiratory effort\n - Hypotension\n - Exhaustion\n - Confusion/altered conscious level\n \n\n# Differential Diagnosis\n \n\nImportant differentials include:\n \n\n - **Pneumothorax**: Very sudden onset, chest pain, possible deviation of the trachea\n - **Anaphylaxis**: Very sudden onset, associated with antigen exposure, may be associated with rash and angioedema\n - **Inhalation of a foreign body**: Unilateral chest signs\n - **Cardiac arrhythmia**: Chest pain or palpitations, tachycardia or changes in blood pressure\n \n\n# Investigations\n\nThe diagnosis of an acute asthma exacerbation is primarily clinical, based on the presenting symptoms and history. Important investigations may include:\n \n - Peak flow meter: to estimate PEFR \n - Spirometry: Reduction in peak expiratory flow rate and FEV1 which improves with treatment confirms the diagnosis\n - Blood tests: To evaluate the inflammatory response and rule out other causes\n - Chest X-ray: In severe cases or when the diagnosis is uncertain\n - ABG may be used if there is a poor response to initial treatment\n \n\n# Management\n \n\nThe management of acute exacerbations of asthma in children, according to the British Thoracic Society and Scottish Intercollegiate Guidelines Network, follows a stepwise approach:\n \n\n - Maintain oxygen saturations between 94-98% with high flow oxygen if necessary.\n - Administer inhaled salbutamol with a pressurised metered dose inhaler and spacer \n - Proceed to nebulised salbutamol (2.5-5 mg) if necessary\n - Add nebulised ipratropium bromide\n - All patients should receive steroids, given IV only if the patient is unable to take the dose orally\n - 20 mg oral prednisolone for children aged 2-5 years\n - 40 mg oral prednisolone for children over 5 years \n - If not tolerating oral, IV hydrocortisone 4 mg/kg every 4 hours can be used \n - Steroids are given for 3 days \n - If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician \n - For consideration of IV magnesium, IV salbutamol or aminophylline\n \nModerate asthma may be managed using oral prednisolone and beta 2 bronchodilator therapy as an outpatient. \n\nIf there are signs of severe or life-threatening asthma, refer to PICU urgently. \n \nDischarge criteria:\n\n- Child stable on their normal salbutamol inhalers every 3-4 hours \n- Peak Expiratory Flow (PEF) or Forced Expiratory Volume in first second of expiration (FEV1) > 75% best or predicted\n- Oxygen saturations >94% on room air\n\n\nFollow-up after discharge:\n \n - The child should be reviewed by their GP within 2 working days to update or create an asthma action plan, check inhaler technique and adherence\n - The child should be discharged on inhaled corticosteroid-containing controller treatment or on an increased dose compared to their pre-existing dose \n - If a child has a near-fatal attack, they will require specialist supervision \n\n# Complications\n\n- Fatigue\n- Pneumothorax \n- Aspiration pneumonia \n- Respiratory failure requiring intubation and ventilation \n- Hypokalaemia and cardiac arrhythmias related to treatment used\n- Hypoxic-ischaemic brain injury \n\n# Prognosis \n\nUnfortunately, outcomes in the UK are some of the worst in Europe, with approximately 25-30 children per year dying of asthma. 90% of these deaths are thought to be preventable with better care and tackling the deprivation that contributes to poor outcomes. \n \n# NICE Guidelines\n \n [BNFc Guidelines for Acute Asthma](https://bnfc.nice.org.uk/treatment-summaries/asthma-acute/) \n \n\n# References\n \n\n [British Thoracic Society Guidelines](https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiL-dbLtOPrAhUXQEEAHbUKAEcQFjACegQIAhAB&url=https%3A%2F%2Fwww.brit-thoracic.org.uk%2Fdocument-library%2Fguidelines%2Fasthma%2Fbtssign-asthma-guideline-quick-reference-guide-2019%2F&usg=AOvVaw0ZD19J5kUP75tRHs2_eoUU)\n \n [Resuscitation Council UK Paediatric emergency algorithms & resources](https://www.resus.org.uk/sites/default/files/2022-03/RCUK%20Paediatric%20emergency%20algorithms%20and%20resources%20Mar%2022%20V1.pdf) \n \n [Patient Info Acute Severe Asthma and Status Asthmaticus](https://patient.info/doctor/acute-severe-asthma-and-status-asthmaticus) \n \n [BMJ Best Practice Acute Asthma in Children](https://bestpractice.bmj.com/topics/en-gb/1098/treatment-algorithm#)",
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"explanation": "# Drug choice feedback\n\nAny short-acting beta-2 agonist is appropriate as first line agent for the treatment of acute asthma. These include salbutamol and terbutaline sulphate, although the former is more commonly prescribed as it is less expensive but no different in efficacy.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose is 2.5mg-5mg for nebulised salbutamol and 5mg-10mg for nebulised terbutaline sulphate respectively. The nebulised route is most preferred in the initial stages of asthma management.",
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"question": "Case Presentation: A 19-year-old gentleman is brought to the Emergency Department with a sudden-onset 2-hour history of shortness of breath and wheezing\n\n\n\n\n## PH\n\n\nAsthma\n\n\n## DH\n\n\nSalbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD (NKDA)\n\n\n## On examination\n\n\nAppears distressed, barely able to answer in full sentences. Wheeze heard throughout both lung fields, no crackles. Use of accessory muscles seen. No cyanosis.\n\n\nTemperature 36.6°C, HR 105, RR 29, BP 110/78, O2 95% RA, GCS 15, Weight 67kg\n\n\n## Investigations\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.41|7.35 - 7.45|\n|PaO₂|16 kPa|11 - 15|\n|PaCO₂|3.8 kPa|4.6 - 6.4|\n|Bicarbonate|25 mmol/L|22 - 30|\n\nCXR normal\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug that is most appropriate to treat his bronchospasm.",
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"explanation": "# Summary \n\nShingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox). It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition. Management normally includes oral antivirals, but intravenous antiviral medications can be used if severe or if the patient is immunocompromised.\n\n# Signs & Symptoms\n\nShingles can manifest first as a tingling feeling in a dermatomal distribution. Progresses to erythematous papules occurring along one or more dermatomes within a few days, which develop into fluid-filled vesicles which then crust over and heal. May be associated with viral symptoms e.g. fever, headache, malaise.\n\n[lightgallery]\n\n[lightgallery1]\n\n**Herpes zoster ophthalmicus (HZO)** presents with symptoms including a painful red eye, fever, malaise, and headache, followed by an erythematous vesicular rash over the trigeminal division of the ophthalmic nerve. A lesion on the nose, known as **Hutchinson's sign,** may suggest ocular involvement.\n\n\n\n# Management\n\n- Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) within 72h of rash onset if immunocompromised (and infection is not severe) or moderate/severe rash or moderate/severe pain, or non-truncal involvement.\n- Admit to hospital for IV antivirals if severe disease or immunocompromise, ophthalmic symptoms or suspicion of meningitis/encaphalitis/myelitis\n- Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact\n- Pain can be managed with NSAIDs (e.g. ibuprofen). If unsuccessful, consider offering amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin\n\n# Shingles vaccine\n\nThere is a one-off vaccine available for shingles that is typically advised for those in their 70s.\n\n# Complications\n\n- Secondary bacterial infection of skin lesions\n- Corneal ulcers, scarring and blindness if eye involved\n- Post-herpetic neuralgia\n - Pain occurring at site of healed shingles infection\n - Can cause neuropathic type pain (burning, pins and needles)\n - Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)\n\n# NICE Guidelines\n\n[NICE Clinical Knowledge Summary (CKS): Shingles](https://cks.nice.org.uk/topics/shingles/)\n\n[NICE Treatment Summary: Varicella-zoster vaccine](https://bnf.nice.org.uk/treatment-summary/varicella-zoster-vaccine-2.html)",
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"question": "Case Presentation: A 51-year-old gentleman sees his GP with a 12-hour history of a painful rash that appeared overnight which was preceded by a mild flu-like illness and itch in the same area. She mentions she has been facing increased stress at work recently.\n\n\n## PH\n\nType 2 Diabetes Mellitus\n\n## DH\n\nMetformin 500mg BD PO (NKDA)\n\n## On examination\n\nAppears well, oriented to time and place. Vesicular rash seen along dermatome T5 on the torso. Otherwise normal.\n\nTemperature 36.1°C, HR 72, RR 13, BP 130/80, O2 96% RA, GCS 15, Weight 82kg\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for treating her rash.",
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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.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,468,096 | false | 4 | null | 6,495,254 | null | false | [] | null | 6,770 | {
"__typename": "QuestionPrescription",
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"__typename": "QuestionComment",
"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\"",
"createdAt": 1645793915,
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"displayName": "Amnesia Kinin",
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"__typename": "QuestionComment",
"comment": "Why not Simvastatin?",
"createdAt": 1646675587,
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"__typename": "QuestionComment",
"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. ",
"createdAt": 1675117037,
"dislikes": 1,
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"displayName": "Axillary Hereditary",
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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. ",
"createdAt": 1646939225,
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"comment": "So it seems simvastatin is almost never the correct answer and atorvastatin almost always is ",
"createdAt": 1737571562,
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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": "Primary prevention of cardiovascular events",
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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.",
"sbaAnswer": null,
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173,468,097 | false | 5 | null | 6,495,254 | null | false | [] | null | 6,772 | {
"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "haematuria but otherwise normal dip - is peel not a concern?",
"createdAt": 1675175921,
"dislikes": 0,
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"displayName": "Prognosis Benign",
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"__typename": "QuestionComment",
"comment": "Is Trimethoprim actually wrong in this case?",
"createdAt": 1706288859,
"dislikes": 0,
"id": "39908",
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"__typename": "QuestionComment",
"comment": "She's allergic to co-trimoxazole, which contains trimethoprim, so best to avoid it :)",
"createdAt": 1737475729,
"dislikes": 0,
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"displayName": "FíonnMacCumhaill",
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"explanation": "# Summary\n\nVesicoureteral reflux (VUR) is a congenital condition where urine flows backwards from the bladder into the ureters and kidneys, increasing the risk of recurrent urinary tract infections (UTIs). Symptoms include recurrent UTIs, fevers, and abdominal pain, with severe cases leading to renal scarring and hypertension. Diagnosis can involve ultrasound, MCUG, MAG reflux test, and DMSA scan. Management includes prophylactic antibiotics, monitoring, and possibly surgery for severe cases. Complications include UTIs, pyelonephritis, and chronic kidney disease.\n\n# Definition\n\nVesicoureteral reflux (VUR) is a condition where urine flows backwards from the bladder into the ureters and potentially the kidneys, rather than the usual one-way flow from the kidneys to the ureters and then to the bladder. This condition is typically present from birth and can lead to recurrent UTIs, as the backward flow of urine can carry bacteria up into the kidneys, causing an infection. It is a significant risk factor for atypical UTIs and recurrent infections.\n \n\n# Epidemiology\n \n\nVUR affects around 1-3% of all children and can occur in all age groups. It is more commonly diagnosed in children with UTIs, especially if these UTIs are recurrent or atypical. A familial predisposition is often present.\n \n\n# Pathophysiology\n\nThe abnormal flow of urine in VUR can occur due to a variety of reasons, including a shortened intravesical ureter (the part of the ureter that passes through the bladder wall), an improperly functioning valve where the ureter joins the bladder, or a neurological disorder affecting the bladder.\n \n\n# Signs and Symptoms\n \nVUR is often asymptomatic and may only be detected when investigating recurrent or atypical UTIs. \n\nSymptoms can include:\n\n- Recurrent UTIs or persistent bacteriuria\n- Unexplained fevers\n- Abdominal or flank pain\n- In severe cases, renal scarring can occur leading to hypertension and chronic kidney disease\n \n\n# Investigations\n \n\nIn children with recurrent or atypical UTIs, investigations considering VUR include:\n \n- Ultrasound of the kidneys and bladder is often performed initially \n - Used to detect hydronephrosis, dilatation of renal pelvis or incomplete bladder voiding \n- Micturating Cystourethrogram (MCUG) \n - Contrast is passed into the bladder, and the patient passes urine whilst x-rays are taken.\n - This enables the refluxing of urine to be visualised \n- MAG (mercapto acetyl triglycine 3) reflux test \n - IV contrast recorded on x-ray whilst the child passes urine, to enable any reflux to be visualised \n- Dimercaptosuccinic acid (DMSA) scan\n - This can detect scarring or damage to the kidneys as a result of VUR\n \n\n# Management\n \n\nThe management of VUR can be conservative or surgical, depending on the severity of the condition, the age of the patient, and the risk of kidney damage. \n\n- Conservative management:\n - Prophylactic antibiotics to prevent UTIs\n - Regular monitoring of kidney function and growth\n - Treatment of constipation if present\n- Surgical treatment, such as ureteral reimplantation, may be considered in severe cases or when conservative management fails.\n \n\n# Complications\n\nPotential complications of VUR include:\n \n\n - Recurrent UTIs\n - Pyelonephritis\n - Renal scarring and Chronic Kidney Disease (CKD)\n - Hypertension\n \nThis highlights the importance of early detection and management of VUR, especially in children with recurrent or atypical UTIs.\n \n# NICE Guidelines \n\n[NICE Guideline Urinary tract infection in under 16s: diagnosis and management](https://www.nice.org.uk/guidance/ng224/chapter/Recommendations-for-research) \n \n# References\n\n[Kidney Research UK Vesicoureteral reflux](https://www.kidneyresearchuk.org/conditions-symptoms/vesico-uretal-reflux/)",
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"explanation": "# Drug choice feedback\n\nThis woman likely has a lower urinary tract infection with no overt complications. In cases whereby there is a low risk of resistance, the two possible first line agents for non-pregnant women include nitrofurantoin or trimethoprim. Given that she is allergic to co-trimoxazole which contains trimethoprim, only nitrofurantoin can be prescribed.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe recommended dose is either 50mg or 100mg, and the frequency is QDS or BD, depending on whether the immediate- or modified-release form is prescribed respectively. It should be prescribed for 3 days. Women who are pregnant and all men who have a lower urinary tract infection require a longer prescription of 7 days.",
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"question": "Case Presentation: A 51-year-old woman attends the GP with urinary frequency, foul-smelling urine and dysuria. She mentions the symptoms are causing her distress. She does not report any loin-to-groin pain nor rigours.\n\n\n## PH\n\nBreast cyst diagnosed 23 years ago, surgically removed without recurrence or complications\n\n## DH\n\nNIL (Allergy to Co-trimoxazole)\n\n## On examination\n\nAlert and oriented. No loin tenderness.\n\nTemperature 36.5°C, HR 75, RR 12, BP 125/79, O<sub>2</sub> 98% RA, GCS 15, Weight 68kg\n\n## Investigations\n\nHaematuria 1+ on dipstick, otherwise normal\n\nUrinary MC&S not appropriate as of now as clinically low risk of resistance.\n\n# Prescribing Request\n\nWrite a prescription for one antibiotic that is most appropriate for treating her condition.",
"sbaAnswer": null,
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173,468,098 | false | 6 | null | 6,495,254 | null | false | [] | null | 6,773 | {
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"__typename": "QuestionComment",
"comment": "How do you know its BD for 6 days / QDS for 3 etc? BNF doesn't say this?",
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"__typename": "QuestionComment",
"comment": "BNF says 'total dose per course should not exceed 6 mg' ",
"createdAt": 1704647264,
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"__typename": "QuestionComment",
"comment": "where does it say how many days?",
"createdAt": 1695752430,
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"__typename": "QuestionComment",
"comment": "surely \"until symptoms resolve\" is correct",
"createdAt": 1706302834,
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"comment": "got it right but got marked wrong loll",
"createdAt": 1737906008,
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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": "2706",
"name": "Gout flare",
"status": null,
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"id": "75",
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"explanation": "# Drug choice feedback\n\nThis gentleman most likely has gout. In the acute setting, the first line agent is usually any NSAID. In light of his chronic kidney disease, this is contra-indicated and the second line agent colchicine has to be used. Recall that allopurinol is not used in the acute setting as it is not effective may prolong the gout attack if started.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe recommended dose is 500 micrograms. It can be given twice to four times a day, as long as the maximum dose given is 6mg. Therefore, the answer given for the duration has to correspond to the dose and frequency chosen.",
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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.",
"sbaAnswer": null,
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"typeId": 4,
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173,468,099 | false | 7 | null | 6,495,254 | null | false | [] | null | 10,057 | {
"__typename": "QuestionPrescription",
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"comments": [
{
"__typename": "QuestionComment",
"comment": "am i missing something, the q said syringe driver so why are we prescribing s/c?",
"createdAt": 1675252534,
"dislikes": 5,
"id": "17537",
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"__typename": "QuestionComment",
"comment": "syringe drivers are SC in palliative care",
"createdAt": 1675258455,
"dislikes": 0,
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"displayName": "Loose Contusion",
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"__typename": "QuestionComment",
"comment": "Syringe drivers are known as continuous subcutaneous injections CSCI",
"createdAt": 1705521378,
"dislikes": 0,
"id": "39141",
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"displayName": "Digiti Minimi",
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"displayName": "Lipsyncope",
"id": 29478
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{
"__typename": "QuestionComment",
"comment": "Can Oxycodone be given in this case? (If the dosage and route is correct?)",
"createdAt": 1706539252,
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"id": "40141",
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"replies": [
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"__typename": "QuestionComment",
"comment": "I do not see why not\n",
"createdAt": 1706732164,
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"displayName": "Acute DNA",
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},
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"__typename": "QuestionComment",
"comment": "can you give 30 mg morphine twice a day?",
"createdAt": 1738151859,
"dislikes": 0,
"id": "61852",
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"displayName": "Juice Defibrillator",
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"explanation": "# Assessing fluid status \n\n- ABCDE approach\n\n- Indications a patient may require fluid resuscitation:\n - Systolic BP <100mmHg\n - Heart rate >90bpm\n - Capillary refill >2s\n - Cool peripheries\n - Respiratory rate >20bpm\n - NEWS ≥5\n - Dry mucous membranes\n\n# Fluid resuscitation \n\n- Identify cause of fluid deficit and respond appropriately\n- Fluid bolus of 500mL crystalloid over <15 minutes\n- Reassess using ABCDE approach\n- Further fluid boluses (up to 2000mL) may be required\n\n# Maintenance fluids \n\n- Assess ability to meet fluid needs enterally\n- Assess fluid deficits, excess losses, abnormal fluid distribution\n\nNormal daily fluid requirements:\n\n- 25-30mL/kg/day water\n- 1mmol/kg/day sodium\n- 1mmol/kg/day potassium\n- 1mmol/kg/day chloride\n- 50–100g/day glucose to limit ketosis\n\n# IV fluids \n\n- Crystalloid = solution containing small molecules e.g. sodium, chloride\n- Colloid = solution containing larger molecules e.g. albumin\n\n**Commonly used fluids**\n\n| Fluid Type | Na+ (mmol/L) | K+ (mmol/L | Cl- | HCO3- | Glucose (mmol/L) |\n| ------------------------------------ | ------------ | ---------- | ------- | ----- | ---------------- |\n| Human plasma (for comparison) | 135-145 | 3.5–5.0 | 100-110 | 22-26 | 3.5-5.5 |\n| Sodium chloride 0.9% (Normal saline) | 154 | | 154 | | |\n| Hartmann's | 131 | 5 | 111 | 29 | |\n| Sodium chloride 0.18%/Glucose 4% | 31 | | 31 | | 222 (40g) |\n| Sodium chloride 0.45%/Glucose 4% | 77 | | 77 | | 222 (40g) |\n| 5% dextrose | | | | | 278 (50g) |\n\n# External links \n\n- [Life In The Fast Lane: Fluids](https://litfl.com/category/ccc/fluids/)\n- [NICE: Algorithms for IV fluid therapy in adults](https://www.nice.org.uk/guidance/cg174/resources/intravenous-fluid-therapy-in-adults-in-hospital-algorithm-poster-set-191627821)\n- [NICE: Composition of commonly used crystalloids](https://www.nice.org.uk/guidance/cg174/resources/composition-of-commonly-used-crystalloids-table-191662813)\n",
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"name": "Fluid prescribing",
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"topic": {
"__typename": "Topic",
"id": "128",
"name": "Palliative",
"typeId": 5
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"dislikes": 4,
"explanation": "## Drug choice feedback\nMorphine sulphate and Diamorphine hydrochloride are opioids used in palliative care to manage pain. Opioids also help relieve dyspnoea and slow the respiratory rate. As this patient was already established on oral morphine, morphine sulphate would be an appropriate choice. Diamorphine hydrochloride can also be used and is more soluble and can be delivered in a smaller volume. Guidance on palliative prescribing in the BNF in the medicines guidance section under 'prescribing in palliative care'.\n\n## Dose/Route/Frequency/Duration feedback\nSubcutaneous morphine should be given at half the daily dose of oral morphine. 120/2 = 60\n\nSubcutaneous diamorphine should be given at a third of the daily dose of oral morphine. 120/3 = 40\n\nSyringe drivers are a machine used to infuse medications slowly via a subcutaneous needle, they are used in palliative care as they are less invasive than intravenous and intramuscular delivery.\n\nSubcutaneous medications are generally prescribed in 24 hourly doses.\n\n*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use. ",
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"__typename": "PrescriptionAnswer",
"dose": {
"__typename": "PrescribeAnswerData",
"label": "60 mg",
"value": 311,
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"label": "40 mg",
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"question": "Case Presentation: A 83-year-old gentleman was admitted to the acute medical ward 4 days ago unwell with a cough and worsening shortness of breath. He has Stage IV small cell lung cancer with spinal metastases. He has been treated with intravenous antibiotics but unfortunately, his condition has worsened. He is now considered to be end-of-life. He was previously on 120mg of oral morphine daily but can no longer tolerate oral medication. \n\n\n## PMH\nStage IV small cell lung cancer\n\n## DH\nMidazolam 20mg SC over 24 hours\n\nHyoscine Hydrobromide 40mg SC over 24 hours\n\nDiscontinued: Morphine Sulphate 60mg BD, Amlodipine 5mg OD\n\n## On examination\nThe patient is drowsy.\n\nOn auscultation of the chest, there is reduced air entry and bronchial breath sounds bilaterally.\n\nHR 90, RR 24, BP 110/84, Temperature 37.5°C\n\n# Prescribing Request\n\nWrite a prescription for one drug that to treat this patient's pain and dyspnoea to be given via a syringe driver.",
"sbaAnswer": null,
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"typeId": 4,
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} | MarksheetMark |
173,468,100 | false | 8 | null | 6,495,254 | null | false | [] | null | 10,103 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "what about docusate?",
"createdAt": 1738065460,
"dislikes": 0,
"id": "61748",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 10103,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Its a softener ",
"createdAt": 1738095918,
"dislikes": 0,
"id": "61807",
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"parentId": 61748,
"questionId": 10103,
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"displayName": "Craniofacial ",
"id": 79947
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"displayName": "Intravenous Power",
"id": 32889
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"id": "3632",
"name": "Treating constipation with osmotic or stimulant laxatives",
"status": null,
"topic": {
"__typename": "Topic",
"id": "129",
"name": "Elderly medicine",
"typeId": 5
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},
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"explanation": "## Drug choice feedback\n\nThis gentleman has constipation. He only wants a stimulant or osmotic laxative - the laxatives that fall inside this group are lactulose, macrogol, bisacodyl, senna and sodium picosulfate. The bulk forming laxatives include ispaghula husk and poo-softener laxatives include docusate.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescriptions are appropriate to treat this man's constipation:\n\n- Lactulose 15ml PO BD\n- Macrogol 2 sachets PO OD\n- Bisacodyl 5-10mg PO OD\n- Senna 7.5-15mg PO ON\n- Sodium picosulfate 5-10mg PO ON",
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"label": "senna 7.5 mg tablets",
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"label": "7 days",
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"__typename": "PrescriptionAnswer",
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"__typename": "PrescribeAnswerData",
"label": "15 mL",
"value": 281,
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"label": "lactulose 10 g/15 mL oral solution",
"value": 2050,
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"__typename": "PrescribeAnswerData",
"label": "7 days",
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"visible": true
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"label": "2 sachets",
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"value": 2025,
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"question": "Case Presentation: A 68-year-old gentleman attends his GP complaining of constipation.\n\n\n\n## PH\nOsteoarthritis, hypercholesterolaemia\n\n## DH\nIbuprofen 400mg PO QDS, lansoprazole 30mg PO OD, atorvastatin 20 mg PO OD\n\n## FHx\n\nNo family history of lower gastrointestinal cancer\n\n## On examination\n\nHe is alert and oriented. Abdomen is soft and non tender, with no palpable organomegaly.\n\nTemperature 36.7°C, HR 70, RR 14, BP 127/82mmHg O<sub>2</sub> 99% RA, GCS 15, Weight 94kg\n\n## Investigations\n\nFBC: Hb 149, WCC 6.1, Plt 271\n\nColonoscopy performed 4 weeks ago: no abnormalities detected.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat this patient's constipation. He would prefer you to prescribe an osmotic or stimulant laxative - not a bulk-forming or poo-softener laxative. He does not want to take any medication rectally.",
"sbaAnswer": null,
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173,468,101 | false | 9 | null | 6,495,254 | null | false | [] | null | 6,778 | {
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"id": "33782",
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"name": "Ibuprofen;400mg;oral (PO);8-hourly",
"picture": null,
"votes": 0
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"id": "33778",
"label": "a",
"name": "Bisoprolol fumarate;10mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"id": "33780",
"label": "c",
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"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"id": "33787",
"label": "j",
"name": "Morphine sulphate;10mg;intravenous (IV);4-hourly",
"picture": null,
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},
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"id": "33786",
"label": "i",
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"id": "33779",
"label": "b",
"name": "Ramipril;2.5mg;oral (PO);Daily",
"picture": null,
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"id": "33785",
"label": "h",
"name": "Senna;7.5mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33784",
"label": "g",
"name": "Ondansetron;4mg;oral (PO);PRN",
"picture": null,
"votes": 0
},
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"id": "33783",
"label": "f",
"name": "Tramadol;100mg;oral (PO);6-hourly",
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"id": "33781",
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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": "2711",
"name": "Post-operative drug induced constipation & drugs that causes fluid retention",
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"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
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"explanation": "1. Common drugs that are stopped prior to surgeries include NSAIDs, diuretics, ACEi and ARBs. ACEi and ARBs are stopped due to the increased risk of peri- and postoperative hypotension. Bisoprolol and calcium channel blockers (amlodipine) are safe and have potential benefits when taken preoperatively. Anticoagulants are also stopped when the surgical bleeding risk outweighs the individual’s thromboembolic risk . Bisoprolol is also generally continued due to the additional risk of ischemia following acute withdrawal. The use of beta blockers cause a sympathetic blockade, which lead to an upregulation of beta receptors and an increase in its responsiveness to circulating catecholamines. Catecholamine levels are elevated during surgery, this results in an increase in myocardial oxygen demand and an exacerbation of ischaemic events. NSAIDs are generally stopped due to its antiplatelet effects (via the inhibition of COX-1 and decreased production of thromboxane A2, preventing platelet aggregation). This increases the bleeding risk perioperatively. Diuretics are stopped due to concerns of hypokalaemia, which increases the risk of perioperative arrhythmia and hypovolaemia, which, in addition to the vasodilating effect of anaesthetic agents can lead to hypotension. Analgesia apart from NSAIDs are generally continued pre-operatively.\nb) Paracetamol is the first step in the WHO analgesic ladder and is commonly used for pain relief. Paracetamol tablets are available in 500mg and 1g tablets but the maximum dose per day is 4g spread evenly over 6 hours or four times a day. The dose prescribed for this patient is likely to represent a transcription error of 6-hrly to 4-hrly.",
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"question": "Case presentation: A 65-year-old gentleman on the gastroenterology ward is recovering from an abdominal peritoneal resection for anal cancer. PH. Hypertension, Type 2 Diabetes, Heart failure, AF. DH. His current regular medications are listed (below).\n\n\nQuestion 1: Select the THREE prescriptions that should be stopped prior to his surgery. (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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173,468,102 | false | 10 | null | 6,495,254 | null | false | [] | null | 6,784 | {
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"id": "33828",
"label": "d",
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"picture": null,
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"id": "33827",
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"picture": null,
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"explanation": null,
"id": "33831",
"label": "g",
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"picture": null,
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"id": "33826",
"label": "b",
"name": "Tetracycline;500mg;oral (PO);12-hourly",
"picture": null,
"votes": 0
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"explanation": null,
"id": "33829",
"label": "e",
"name": "Levothyroxine;200micrograms;oral (PO);Daily",
"picture": null,
"votes": 0
},
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"answer": false,
"explanation": null,
"id": "33830",
"label": "f",
"name": "Amitriptyline;50mg;oral (PO);Daily",
"picture": null,
"votes": 0
},
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"answer": false,
"explanation": null,
"id": "33825",
"label": "a",
"name": "Fluoxetine;20mg;oral (PO);Daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"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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"explanation": "1. The use of SSRI such as fluoxetine is known to cause congenital heart diseases especially when taken during early pregnancy. Lithium, a medication used for bipolar disorder, is associated with increased risk of Ebstein’s anomaly when taken in the first trimester.\n2. Despite evidence showing that calcium in breast milk prevents the absorption of tetracycline, it is currently still avoided in breastfeeding women. Aspirin increases the risk of Reye’s syndrome. Fluoxetine and lithium carbonate is present in milk and can carry a risk of toxicity in infant.",
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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).",
"sbaAnswer": null,
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173,468,103 | false | 11 | null | 6,495,254 | null | false | [] | null | 6,788 | {
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"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33856",
"label": "c",
"name": "Chlortalidone;50mg;Oral (PO);Daily",
"picture": null,
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"explanation": null,
"id": "33859",
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"explanation": null,
"id": "33861",
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"picture": null,
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"explanation": null,
"id": "33858",
"label": "e",
"name": "Simvastatin;40mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33854",
"label": "a",
"name": "Amlodipine;5mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"explanation": null,
"id": "33860",
"label": "g",
"name": "Fluoxetine;100mg;Oral (PO);Daily",
"picture": null,
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"explanation": null,
"id": "33857",
"label": "d",
"name": "Cetirizine hydrochloride;10mg;Oral (PO);Daily",
"picture": null,
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"__typename": "QuestionComment",
"comment": "Hyponatremia is rare in fluoxetine and unknown in losartan. How do we know which one to put since supposedly we dont need much theory to be able to do the PSA",
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"comment": "Do ARBs not cause hyponatraemia too",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Dosing error & drugs causing hyponatremia",
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"explanation": "1. Chlortalidone is a thiazide-like diuretic that inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. Bumetanide is a loop diuretic that acts on the Na+-K+-2Cl− symporter (NKCC2) in the thick ascending limb of the loop of Henle to inhibit sodium, chloride and potassium reabsorption. Both chlortalidone and bumetanide are known to cause hyponatraemia. Hyponatraemia is also a recognised side effect of fluoxetine. BNF cautions against prescribing fluoxetine to elderly patients with significant hyponatraemia i.e. serum sodium less than 130 mmol/L due to risk of exacerbating or precipitating hyponatraemia.\n2. The maximum daily dose of fluoxetine is 60mg.",
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"question": "Case presentation: A 45-year old man attends his GP appointment complaining of nausea and tiredness. PH: Hypertension, Allergic rhinitis, Hypercholesterolaemia, Peripheral oedema, Vitamin D deficiency DH: His 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. Abdomen soft and non-tender.\n\n\n **Vital signs**: BP 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|130 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|300x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|90 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|125 mmol/L|135 - 145|\n|Potassium|4 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|109 µmol/L|60 - 120|\n|Thyroid Stimulating Hormone|3.8 mU/L|0.3 - 4.2|\n|Free T4|17 pmol/L|9 - 25|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of his hyponatraemia (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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173,468,104 | false | 12 | null | 6,495,254 | null | false | [] | null | 6,794 | {
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33902",
"label": "a",
"name": "Sodium feredetate;2.5ml;Oral (PO);Three times daily",
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"__typename": "QuestionChoice",
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"label": "d",
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"id": "33904",
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"comment": "oh cmon",
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"comment": "Are steroids not contraindicated in GORD?",
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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. The dose of dexamethasone for croup is 150 micrograms/kg. The girl is 15kg in weight. Hence, the correct dose that should be prescribed is 2.25mg.\n2. Tetracycline is contra-indicated in children under 12 years. Tetracycline binds to calcium and gets deposited in growing bone and teeth. Use of tetracycline in children is associated with teeth staining and dental hypoplasia.",
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"question": "Case presentation: A 3-year-old girl is brought to the emergency department by her mother in the middle of night. The little girl has developed a fever and a sudden-onset seal-like “barking” cough. Her weight is 15kg PH: Constipation, Anaemia, Rosacea, GORD DH: Her current regular prescriptions are listed below\n\n\n**On examination**: Seal-like barking cough, hoarse cry and an inspiratory stridor when crying\n\n**Vital signs**: Temperature 37.8°C, HR 125, O2 Sat 99% (room air), RR 30\nCroup (acute laryngotracheobronchitis) is suspected and treatment is commenced.\n\nQuestion 1: Select the ONE prescription that contains a serious dosing error. (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that is contra-indicated. (mark it with a tick in column B)",
"sbaAnswer": null,
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173,468,105 | false | 13 | null | 6,495,254 | null | false | [] | null | 6,797 | {
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{
"__typename": "QuestionChoice",
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"id": "33927",
"label": "f",
"name": "Omeprazole;20mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33926",
"label": "e",
"name": "Metoclopramide hydrochloride;100mg;Oral (PO);8-hourly when required",
"picture": null,
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},
{
"__typename": "QuestionChoice",
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"id": "33928",
"label": "g",
"name": "Allopurinol;100 mg;Oral (PO);Daily",
"picture": null,
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"id": "33923",
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"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
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},
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"id": "33922",
"label": "a",
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"picture": null,
"votes": 0
},
{
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"id": "33925",
"label": "d",
"name": "Ibuprofen;400mg;Oral (PO);4-hourly when required",
"picture": null,
"votes": 0
},
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"id": "33924",
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"name": "Fluoxetine;40 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
}
],
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{
"__typename": "QuestionComment",
"comment": "4-hourly ibuprofen is also a significant dosing error??",
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"comment": "So is 8-hourly 100mg metoclopramide no...?",
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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. Hyperprolactinaemia is a common or very common side effect of chlorpromazine and an uncommon side effect of metoclopramide. Both chlorpromazine and metoclopramide have dopamine D2 receptor antagonistic property, leading to disinhibition of excessive prolactin production. Hyperprolactinaemia is also rare or very rare side effect of all selective serotonin reuptake inhibitors (SSRI). A SSRI like fluoxetine is thought to cause hyperprolactinaemia by inducing a 5HT receptor–mediated stimulation of prolactin secretion.\n2. The correct dose of metoclopramide for acute migraine should be 10mg and not 100mg.",
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"question": "Case presentation: A 35-year old woman presents to her GP with amenorrhoea. She reports that she has missed her period and that her menstrual cycle has been irregular for the past few months. She also notices white, milky discharge from her breasts. Besides that, she also informs that she has been trying to conceive for two years but is not successful. PH: Type 2 Diabetes Mellitus, Schizophrenia, Depression, Migraine, GORD, Gout DH: Her current regular prescriptions are listed below\n\n\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\n **Investigation:**\nNegative human chorionic gonadotrophin (HCG) pregnancy test\nSerum prolactin: 850 mIU/L (<500)\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to the hyperprolactinaemia (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)",
"sbaAnswer": null,
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173,468,106 | false | 14 | null | 6,495,254 | null | false | [] | null | 6,798 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33933",
"label": "e",
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"id": "33935",
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"name": "Phenoxymethylpenicillin;5 mg;Oral (PO);6-hourly",
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"explanation": null,
"id": "33929",
"label": "a",
"name": "Enalapril maleate;20 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
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"explanation": null,
"id": "33931",
"label": "c",
"name": "Simvastatin;40mg;Oral (PO);Nightly",
"picture": null,
"votes": 0
},
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"explanation": null,
"id": "33930",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times daily",
"picture": null,
"votes": 0
}
],
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"__typename": "QuestionComment",
"comment": "Wouldn't ibuprofen also be avoided during pregnancy?",
"createdAt": 1642174226,
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"id": "6438",
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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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"__typename": "QuestionComment",
"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?",
"createdAt": 1643646378,
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"id": "6856",
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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",
"createdAt": 1738010839,
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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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"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,
"userPoint": null
} | MarksheetMark |
173,468,107 | false | 15 | null | 6,495,254 | null | false | [] | null | 10,110 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50272",
"label": "f",
"name": "Hydroxychloroquine;200mg;PO;OD",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50271",
"label": "e",
"name": "Nifedipine;5mg;PO;TDS",
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"id": "50270",
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"id": "50273",
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"id": "50268",
"label": "b",
"name": "Lithium carbonate (Liskonum);450mg;PO;OD",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50274",
"label": "h",
"name": "Lansoprazole;30mg;PO;OD",
"picture": null,
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"id": "50275",
"label": "i",
"name": "Paracetamol;1g;PO;QDS",
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50269",
"label": "c",
"name": "Gabapentin;300mg;PO;TDS",
"picture": null,
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}
],
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"__typename": "QuestionComment",
"comment": "paracetamol 1g qds is right ?",
"createdAt": 1706743704,
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"comment": "yes max 4g/d",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"id": "3639",
"name": "Taking both sertraline and lithium increases the risk of serotonin syndrome and a dosing error in tramadol",
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"explanation": "1. This patient is experiencing serotonin syndrome. This can be inferred from the classic symptoms of diarrhoea, vomiting and muscle spasms combined with the dilated pupils and profuse sweating seen on examination. Tramadol and lithium increase the risk of serotonin syndrome in patient's taking sertraline. Tramadol is does this by increasing the concentration of serotonin in the synapses between the serotonergic neurones in the brain stem.\n2. The max dose of tramadol should be 400mg daily. This patient would be receiving 10 times the maximum daily dose.",
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"question": "Case presentation: \n\n\nA 24-year-old woman attends the emergency department due to diarrhoea, vomiting and muscle spasms.\n\n**PH** Depression, anxiety, bipolar disorder, fibromyalgia, Raynaud's syndrome, systemic lupus erythematosus\n\n**DH** Her regular medicines are listed (below). Weight 67kg.\n\n**On Examination**\nHR 128/min regular rhythm, BP 164/97 mmHg, profusely sweating, dilated pupils.\n\nQuestion 1: Select the TWO prescriptions that are most likely to have interacted with her sertraline to cause this presentation (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,468,108 | false | 16 | null | 6,495,254 | null | false | [] | null | 10,112 | {
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"label": "b",
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"picture": null,
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"label": "i",
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"id": "50288",
"label": "d",
"name": "Salbutamol;200 micrograms;INH;PRN",
"picture": null,
"votes": 0
}
],
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"__typename": "QuestionComment",
"comment": "this is wrong because you only reduce the dose of apixaban if there is at least 2 criteria, one being age. (this guy has), the others being weight of 60 or less (which he is not) and creat > 133 (not told)",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "A common side effect of beta blockers, statins and selective serotonin reuptake inhibitors is sleep disorders and a felodipine prescription error",
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"explanation": "1. Beta blockers, statins and mirtazapine all commonly can cause sleep disorders. Beta-blockers interfere with sleep by reducing melatonin levels due to inhibition of beta-1 adrenergic receptors. SSRIs disturb the regulation of muscle tone during REM sleep and exacerbate bruxism.\n2. The maximum dose of apixaban in this patient is 2.5mg BD, as they are >80 years of age and <60kg. Other indications for reduced apixaban usage include: serum creatinine 133 micromol/litre and over, and patients with two of these criteria require reduced dosing.",
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173,468,109 | false | 17 | null | 6,495,254 | null | false | [] | null | 6,808 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Pivmecillinam cannot be given as the patient is penicillin-allergic",
"id": "33988",
"label": "d",
"name": "Pivmecillinam hydrochloride 200mg PO TDS",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"id": "33989",
"label": "e",
"name": "Trimethoprim 200mg PO BD",
"picture": null,
"votes": 186
},
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"__typename": "QuestionChoice",
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"explanation": "Amoxicillin cannot be given as the patient is penicillin-allergic",
"id": "33986",
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"picture": null,
"votes": 102
},
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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",
"id": "33987",
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"name": "Nitrofurantoin 100mg PO BD",
"picture": null,
"votes": 2391
},
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"answer": true,
"explanation": "Fosfomycin is an acceptable alternative in treating uncomplicated lower urinary tract infections if first-line treatments are ineffective or contraindicated",
"id": "33985",
"label": "a",
"name": "Fosfomycin 3g PO OD",
"picture": null,
"votes": 2222
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],
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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.",
"sbaAnswer": [
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173,468,110 | false | 18 | null | 6,495,254 | null | false | [] | null | 6,817 | {
"__typename": "QuestionSBA",
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"explanation": "For females with PCOS that have not improved following treatment with a first line option such as topical treatments, consider adding ethinylestradiol with cyproterone (co-cyprindiol) and review at 6 months, as per [NICE Guidance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)",
"id": "34030",
"label": "a",
"name": "Co-cyprindiol 2000/35 micrograms PO OD",
"picture": null,
"votes": 2110
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a combined contraceptive pill formulation. This is recommended as second line treatment (though it is unlicensed) for acne in patients with PCOS if co-cyprindiol is ineffective, as per [NICE Guidelance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)",
"id": "34032",
"label": "c",
"name": "Combined oral contraceptive pill",
"picture": null,
"votes": 2737
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting or to a woman of childbearing age absent a pregnancy prevention plan due to its potent teratogenic effects",
"id": "34031",
"label": "b",
"name": "Isotretinoin 20mg PO BD",
"picture": null,
"votes": 88
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an alternative topical treatment for acne vulgaris",
"id": "34033",
"label": "d",
"name": "Nicotinamide gel topical BD",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an oral treatment option for acne vulgaris that has not responded to topical treatments",
"id": "34034",
"label": "e",
"name": "Tetracycline 500mg PO BD",
"picture": null,
"votes": 267
}
],
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"__typename": "QuestionComment",
"comment": "is co-cyprindiol not regarded as a COCP? im confused",
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"comment": "i think they just want you to be more specific - co-cyprindiol is the best for hirsutism and pcos related symptoms out of all the cocp, and this is an SBA so it's a better answer. can try other formulations afterwards if co-cyprindiol not effective",
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"comment": "the co-cyprindiol guidelines can be found under acne treatment summary and then 'reassessment and further treatment' If anyone was wondering :)",
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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 28 year old woman presents to her GP with a longstanding history of acne. She has tried various topical creams and ointments in the past that have only resulted in very modest improvement, and wonders if there is anything else that can be prescribed. **PH** acne vulgaris. **DH** benzoyl peroxide gel, azelaic acid 20% cream (Skinoren).\n\n\nHer BMI is 28kg/m^2. On further questioning, she also reveals that she has had to engage in waxing her upper lip and chin since the age of 17, and describes erratic menstrual cycles ranging anywhere from 21 days to as long as 90 days. She has never been pregnant before, is sexually active and uses barrier protection as contraception as she is not looking to start a family.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,468,111 | false | 19 | null | 6,495,254 | null | false | [] | null | 6,821 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms",
"id": "34054",
"label": "e",
"name": "Stop allopurinol and prescribe prednisolone 20mg PO for 7 days",
"picture": null,
"votes": 71
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms",
"id": "34053",
"label": "d",
"name": "Stop allopurinol and prescribe naproxen sodium 500mg PO stat",
"picture": null,
"votes": 343
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should not switch their drugs during an acute flare as this can worsen symptoms",
"id": "34051",
"label": "b",
"name": "Change allopurinol to febuxostat 120mg PO OD",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. As NSAIDs should be avoided in this patient, colchicine can be given as an alternative",
"id": "34050",
"label": "a",
"name": "Continue allopurinol and prescribe colchicine 500 micrograms PO BD for 3 days",
"picture": null,
"votes": 4354
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. NSAIDs are generally recommended first line but this patient has a history of GORD and hence they would not be suitable",
"id": "34052",
"label": "c",
"name": "Continue allopurinol and prescribe diclofenac sodium 75mg PO BD for 7 days",
"picture": null,
"votes": 427
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Why should NSAIDs be avoided in this patient?",
"createdAt": 1704388313,
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"comment": "GORD, increased GI bleeding",
"createdAt": 1704550822,
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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 48 year old man presents to his GP with a 48 hour history of pain in his right foot. **PH** type 2 diabetes, GORD, gout. **DH** metformin hydrochloride 500mg PO TDS, sitagliptin 100mg PO OD, esomeprazole 20mg PO OD, allopurinol 200mg PO OD, paracetamol 1g PO QDS.\n\n\n**O/E**\n\nSwollen, erythematous 1st metatarsophalangeal joint on right foot. No other joints involved. Left foot grossly normal.\n\nTemperature 36.4°C.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
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173,468,112 | false | 20 | null | 6,495,254 | null | false | [] | null | 6,822 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The patient is already receiving 2g of metformin hydrochloride and as such this prescription would not effect any significant change to the overall medical treatment this patient is currently receiving",
"id": "34059",
"label": "e",
"name": "Change his prescription to metformin hydrochloride modified release 2g PO OD",
"picture": null,
"votes": 281
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Repaglinide is an oral antidiabetic medication used to treat type 2 diabetes. It is less preferred than sulfonylureas",
"id": "34057",
"label": "c",
"name": "Add repaglinide 500 micrograms PO with meals to his current prescription",
"picture": null,
"votes": 139
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a GLP-1 mimetic that is used to treat type 2 diabetes. It should not be prescribed in the primary care setting and is usually only considered failing treatment with more preferred oral antidiabetic medications",
"id": "34056",
"label": "b",
"name": "Add exenatide 5 micrograms SC BD to his current prescription",
"picture": null,
"votes": 53
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "In treating type 2 diabetes, it is recommended that a second antidiabetic drug be added following an inadequate response to maximal therapy with metformin",
"id": "34055",
"label": "a",
"name": "Add gliclazide 40mg PO OD to his current prescription",
"picture": null,
"votes": 4256
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This prescription would exceed the recommended maximum dose of metformin which is 2g per day",
"id": "34058",
"label": "d",
"name": "Change his prescription to metformin hydrochloride 1g PO TDS",
"picture": null,
"votes": 139
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "but isn't his glucose control improving?\n",
"createdAt": 1678670855,
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"comment": "HbA1c >58mmol/L warrants the addition of another diabetic medication",
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"comment": "I don't think it's as black and white as that. The point is that after 3 months his glucose has barely improved at all. Were it 59 mmol/L, I suspect you wouldn't add another drug. Someone can correct me if I'm wrong 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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"question": "Case Presentation: A 54 year old man attends a follow-up appointment at his GP. Six months ago, he was previously diagnosed with type 2 diabetes and started on metformin hydrochloride 500mg PO OD. This has since been up-titrated to 500mg PO TDS, then 500mg PO QDS.\n\n\n**Investigations**\n\nHbA1C (3 months ago): 64 mmol/mol\n\nHbA1C (now): 61 mmol/mol\n\nUrine dipstick: NAD\n\nQuestion: Select the most appropriate management at this stage.",
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173,468,113 | false | 21 | null | 6,495,254 | null | false | [] | null | 10,066 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
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"explanation": "This patient has suspected meningitis with meningococcal septicaemia. Intramuscular Benzylpenicillin is the most appropriate treatment in a pre-hospital environment, i.e. general practice, community, or ambulance. As this patient is already at A&E, IV treatments would be available and more appropriate.",
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"explanation": "This patient has suspected meningitis with meningococcal septicaemia. IV Cefotaxime or Ceftriaxone would be the most appropriate initial treatment in a hospital setting.",
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"explanation": "Phenoxymethylpenicillin is the chosen antibiotic to treat tonsillitis, oral infections and otitis media. This patient has suspected meningitis with meningococcal septicaemia.",
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"explanation": "Flucloxacillin is the chosen antibiotic to treat infections such as otitis externa and severe pneumonia in children. This patient has suspected meningitis with meningococcal septicaemia.",
"id": "50094",
"label": "d",
"name": "Flucloxacillin 325mg IM",
"picture": null,
"votes": 4
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"explanation": "IV Amoxicillin is the treatment for meningitis caused by listeria. This patient has suspected meningitis with meningococcal septicaemia.",
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"picture": null,
"votes": 24
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 2-year-old girl is brought into A&E by her father. She has been unwell for 24 hours. She is drowsy and disinterested in playing. She has recently developed a non-blanching rash over her torso. **PH** None **DH** NKDA\n\n\n**On examination**\nThe patient is drowsy with her eyes closed.\n\nNon-blanching erythematous rash seen over her torso.\n\nHR 134, RR 32, Capillary Refill 3 seconds\n\nWeight: 13kg\n\n**Investigations**\n\nNone performed yet\n\nQuestion: Select the most appropriate management at this stage.",
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173,468,114 | false | 22 | null | 6,495,254 | null | false | [] | null | 10,068 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst it is correct to prescribe an oral aminosalicylate, this dosage of sulfasalazine is for inducing remission NOT maintaining it.",
"id": "50104",
"label": "d",
"name": "Prescribe sulfasalazine 2g PO QDS",
"picture": null,
"votes": 311
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has had a mild-moderate exacerbation of his ulcerative colitis. To maintain remission following this severity of episode it is appropriate to prescribe an oral aminosalicylate, in this case sulfasalazine.",
"id": "50101",
"label": "a",
"name": "Prescribe sulfasalazine 500mg PO QDS",
"picture": null,
"votes": 2544
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is clinically well, there is no need to readmit him.",
"id": "50103",
"label": "c",
"name": "Admit to hospital for a course of IV prednisolone",
"picture": null,
"votes": 7
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a mild-moderate exacerbation of his ulcerative colitis. Prescribing oral prednisolone to maintain remission is not appropriate.",
"id": "50102",
"label": "b",
"name": "Prescribe prednisolone 10mg PO OD",
"picture": null,
"votes": 50
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has just had their first exacerbation of ulcerative colitis. Offering no pharmacological intervention would most certainly mean a further exacerbation of ulcerative colitis in the near future.",
"id": "50105",
"label": "e",
"name": "Offer lifestyle advice",
"picture": null,
"votes": 388
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"comment": "fully depends on the location of the issue",
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"comment": "Nope it doesn't. BNF: 'A low-dose of oral aminosalicylate is given to maintain remission in patients after a mild-to-moderate inflammatory exacerbation of left-sided or extensive ulcerative colitis' ",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 34 year old man attends an outpatient IBD clinic for a review of his ulcerative colitis. \n\n\nHe has recently been discharged after having a first flair of mild-moderate disease. He is experiencing no symptoms.\n\n**PH** Ulcerative colitis\n\n**DH** Nil. NKDA.\n\n**On examination**\n\nTemperature 36.9°C, HR 62, RR 12, BP 114/73, O2 98% RA\n\nAbdomen is soft and non-tender.\n\nQuestion: Select the most appropriate management at this stage.",
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173,468,115 | false | 23 | null | 6,495,254 | null | false | [] | null | 10,069 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are all management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability.",
"id": "50107",
"label": "b",
"name": "Stop his apixaban, take a group and save blood sample and continue to monitor",
"picture": null,
"votes": 461
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "These are management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability. You should also get a group and save and crossmatch sample.",
"id": "50108",
"label": "c",
"name": "Stop his apixaban and continue to monitor",
"picture": null,
"votes": 35
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has suffered an acute bleed. They are haemodynamically unstable due to the hypotension and tachycardia. They also have a low Hb of 68 with the transfusion threshold being a Hb of 70 (80 in patients with a significant cardiac history). He should therefore have all blood thinners suspended and a unit of O negative blood given STAT. You should also get a group and save and crossmatch sample.",
"id": "50106",
"label": "a",
"name": "Stop his apixaban, take a group and save blood sample and prescribe a unit of O negative blood STAT",
"picture": null,
"votes": 2691
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Stopping the apixaban would be one of the correct steps in the management of this patient. Giving vitamin K however will have no effect as this reverses the effects of warfarin NOT apixaban. You should also give a unit of blood STAT.",
"id": "50109",
"label": "d",
"name": "Stop his apixaban, prescribe vitamin K 2mg PO STAT",
"picture": null,
"votes": 43
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst a unit of blood is needed as soon as possible you should always also stop medications that will exacerbate the bleed - in this case the apixaban needs to be stopped.",
"id": "50110",
"label": "e",
"name": "Prescribe a unit of O negative blood STAT",
"picture": null,
"votes": 48
}
],
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"__typename": "QuestionComment",
"comment": "does anyone know if there is a tx summary or page on transfusion thresholds or bleeding?",
"createdAt": 1737924509,
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"comment": "Not sure but it is HB<80 in ACS and Hb<70 otherwise",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 76 year old man is brought to the emergency department due to a PR bleed. He is unsure how much blood he has lost. \n\n\n\n\n **PH** Diverticular disease, atrial fibrillation, hypercholesterolaemia\n\n\n **DH** Bisoprolol 5mg PO OD, apixaban 5mg PO BD, atorvastatin 20mg PO OD. NKDA\n\n\n **On examination**\n\n\nTemperature 37.4°C, HR 108, RR 18, BP 94/68, O2 95% RA.\n\n\n **Investigations**\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|68 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|333x10<sup>9</sup>/L|150 - 400|\n|C Reactive Protein|48 mg/L|< 5|\n\n\nQuestion: Select the most appropriate management at this stage.",
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a lower UTI. If she was not pregnant then this treatment option would be okay however it is contraindicated during pregnancy due to its anti-folate properties.",
"id": "50320",
"label": "b",
"name": "Trimethoprim 200mg PO BD",
"picture": null,
"votes": 22
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"__typename": "QuestionChoice",
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"explanation": "This patient has a lower UTI. As she is pregnant she should NOT be prescribed trimethoprim which leaves nitrofurantoin as the first line medication she should be prescribed.",
"id": "50319",
"label": "a",
"name": "Nitrofurantoin MR 100mg PO BD",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amoxicillin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.",
"id": "50321",
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"picture": null,
"votes": 171
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clarithromycin isn't typically prescribed to treat lower UTIs. This particular dose of clarithromycin is used to treat cellulitis.",
"id": "50323",
"label": "e",
"name": "Clarithromycin 500mg PO BD",
"picture": null,
"votes": 4
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cefalexin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.",
"id": "50322",
"label": "d",
"name": "Cefalexin 500mg PO BD",
"picture": null,
"votes": 90
}
],
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"question": "Case Presentation: A 24 year old pregnant woman attends her GP due to dysuria. She is 12 weeks pregnant.\n\n\n**PH** Nil.\n\n**DH** Nil. NKDA\n\n**Investigations**\n\nUrine dip:\n\n* Blood: -\n* Nitrates: ++\n* White blood cells: ++\n* Red blood cells: -\n\nQuestion: Select the most appropriate management at this stage.",
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
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"explanation": "Dose of prednisolone needs to be reduced gradually before the treatment is stopped completely to reduce the risk of withdrawal symptoms",
"id": "34092",
"label": "c",
"name": "She should immediately stop taking prednisolone once her symptoms have improved to reduce the risk of developing side effects",
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},
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"__typename": "QuestionChoice",
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"explanation": "Prednisolone could cause insomnia through the release of catecholamines. Hence, patients are usually advised to take prednisolone in the morning so that it does not keep them awake at night",
"id": "34091",
"label": "b",
"name": "She should take prednisolone at night before sleeping",
"picture": null,
"votes": 139
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Peptic ulcer is a common side effect of all systemic corticosteroids",
"id": "34093",
"label": "d",
"name": "Prednisolone decreases the risk of peptic ulcer",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Prednisolone is not known to cause hypoglycaemia",
"id": "34094",
"label": "e",
"name": "Prednisolone increases the risk of hypoglycaemia",
"picture": null,
"votes": 144
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Prednisolone is a steroid medication used to reduce inflammation in rheumatological condition such as polymyalgia rheumatica. During sickness, patients are advised to increase the dose of prednisolone for two days before returning to the usual dose. This action aims to mimic the natural response of adrenal glands that increase the production of steroid hormones during illness",
"id": "34090",
"label": "a",
"name": "She should double the dose of prednisolone during sickness",
"picture": null,
"votes": 4729
}
],
"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": "2762",
"name": "Steroid Sick Day Rule",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"question": "Case presentation: A 60-year-old woman attends the rheumatology clinic with a two-week history of fatigue and morning stiffness in the shoulder. She complains that the stiffness usually lasts more than 1 hour. \n\n\nInvestigations:\n -ESR 45mm/hr [(age+10)/2]\n -CRP 20 mg/l (<10 )\nA diagnosis of polymyalgia rheumatica is made and patient is advised to commence treatment with Prednisolone 10 mg PO daily.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 5097,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,118 | false | 26 | null | 6,495,254 | null | false | [] | null | 6,830 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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,
"votes": 2
},
{
"__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,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": true,
"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",
"picture": null,
"votes": 4943
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": false,
"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,
"votes": 35
}
],
"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,
"highlights": [],
"id": "2618",
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"typeId": 2
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"demo": null,
"entitlement": null,
"id": "2763",
"name": "Alendronic acid",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 5007,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,119 | false | 27 | null | 6,495,254 | null | false | [] | null | 6,834 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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. It is important to remind patients that unlike beta-agonist inhaler, a beclometasone inhaler needs to be used every day even if they do not experience any symptoms",
"id": "34116",
"label": "b",
"name": "He should not use his beclometasone inhaler if he does not experience any symptoms",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": true,
"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",
"picture": null,
"votes": 4909
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"label": "c",
"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",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"picture": null,
"votes": 37
}
],
"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": "2767",
"name": "Steroid inhaler",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 4982,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,120 | false | 28 | null | 6,495,254 | null | false | [] | null | 6,840 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"id": "34148",
"label": "d",
"name": "She will be protected against sexually transmitted disease",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Contraceptive implants are more than 99% effective while as COCPs are generally less than 95% effective with typical use (NHS website: https://www.nhs.uk/conditions/contraception/which-method-suits-me/). Percentage of women experiencing an unintended pregnancy within the first year of typical use is 0.005% for progestogen-only implant and 9% for COCP. [NICE CKS: https://cks.nice.org.uk/contraception-assessment#!backgroundSub]",
"id": "34146",
"label": "b",
"name": "With typical use, it is more effective than contraceptive implant in preventing pregnancy",
"picture": null,
"votes": 32
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "COCP is associated with a small increased risk of cervical cancer if used for 5 years or longer",
"id": "34149",
"label": "e",
"name": "It decreases the risk of developing cervical cancer",
"picture": null,
"votes": 74
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"picture": null,
"votes": 152
},
{
"__typename": "QuestionChoice",
"answer": true,
"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",
"id": "34145",
"label": "a",
"name": "It is linked to an increased risk of developing breast cancer",
"picture": null,
"votes": 4724
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"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/)",
"files": null,
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"id": "2772",
"name": "Combined Oral Contraceptive Pill",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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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.",
"sbaAnswer": [
"a"
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"totalVotes": 4984,
"typeId": 1,
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} | MarksheetMark |
173,468,121 | false | 29 | null | 6,495,254 | null | false | [] | null | 10,070 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should be applied in the direction of hair growth to reduce the risk of irritation to hair follicles.",
"id": "50114",
"label": "d",
"name": "Apply to the skin against the direction of hair growth",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. The slowing of growth in children is a serious but very rare side effect of prolonged corticosteroid use. This is very unlikely where low doses are used short-term, as in this case, and so would be inappropriate information to provide at this stage.",
"id": "50115",
"label": "e",
"name": "Slowing growth is a common side effect",
"picture": null,
"votes": 56
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. The dose of steroid creams is often given in FTUs. One FTU is the amount of cream in a line squeezed out from the tip of the finger to the first crease, this is approximately 500mg. One FTU is enough to cover one hand, front and back.",
"id": "50113",
"label": "c",
"name": "One fingertip unit (FTU) is enough to cover the palm of one hand",
"picture": null,
"votes": 764
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should only be applied once or twice daily to reduce the risk of side effects such as skin thinning and skin depigmentation. Emollients used to moisturise the eczematous skin should be applied 3-4 times daily.",
"id": "50112",
"label": "b",
"name": "Apply the cream 3-4 times daily",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should be applied thinly to reduce the risk of side effects such as skin thinning and skin depigmentation.",
"id": "50111",
"label": "a",
"name": "Apply the cream thinly to the affected areas",
"picture": null,
"votes": 2334
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Topical Corticosteroids",
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"question": "Case presentation: A 14-year-old girl attends the GP with erythematous, itchy and sore skin in her elbow and knee flexures. The GP prescribes her 1% Hydrocortisone cream to manage this. \n\n\n**PH**\nAtopic eczema\n\n**DH**\nE45 Lotion\nNKDA\n\nQuestion: Select the most important information that should be provided for this patient.",
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"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
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"explanation": "Patients are advised to inject insulin at a different site each time to prevent lipohypertrophy and excessive skin irritation.",
"id": "50117",
"label": "b",
"name": "Insulin should be injected at the same site each time",
"picture": null,
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"explanation": "Blood glucose measurements should generally be taken before each meal and at bedtime. These measurements may be taken more regularly when a child is newly diagnosed with Diabetes.",
"id": "50119",
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"name": "Blood glucose should be checked after each meal with a finger prick",
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"explanation": "Insulin pens should be kept in the fridge. The low temperatures of a freezer may damage the insulin.",
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"explanation": "A side effect of insulin is weight gain, not weight loss.",
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"explanation": "Glucose tablets and glucose gel, as well as sugary sweets and drinks, can be used to treat hypoglycaemia. Insulin therapy leaves patients at a greater risk of hypoglycaemia. Patients and their parents should be educated on what to do if they experience hypoglycaemia.",
"id": "50116",
"label": "a",
"name": "Start carrying glucose tablets or glucose gel",
"picture": null,
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}
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case presentation: An 8-year-old boy receives a new diagnosis of type 1 diabetes mellitus after being admitted to the hospital with diabetic ketoacidosis. \n\n\n**PH**\nType 1 Diabetes Mellitus\nDowns Syndrome\n\n**DH**\nNKDA\n\nManagement with an insulin regime is initiated.\n\nQuestion: Select the most important information that should be provided to this patient and their parents.",
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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",
"files": null,
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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",
"highlights": [],
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"dose": "2.25",
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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?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,468,124 | false | 32 | null | 6,495,254 | null | false | [] | null | 6,923 | {
"__typename": "QuestionQA",
"choices": [],
"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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"name": "Drug Calculations",
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"id": "75",
"name": "GP",
"typeId": 5
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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",
"highlights": [],
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"dose": "45",
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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,
"totalVotes": null,
"typeId": 2,
"userPoint": null
} | MarksheetMark |
173,468,125 | false | 33 | null | 6,495,254 | null | false | [] | null | 6,925 | {
"__typename": "QuestionQA",
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"__typename": "QuestionComment",
"comment": "Mentioning that the infusion is done twice a day leads to much confusion. The question is not worded properly.",
"createdAt": 1647108410,
"dislikes": 2,
"id": "8479",
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"comment": "That's sometimes the point with these questions. They give you unnecessary information / distractors in the real PSA too.",
"createdAt": 1738173992,
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"id": "2618",
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"typeId": 2
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"demo": null,
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"id": "2857",
"name": "Calculation of infusion rate",
"status": null,
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"id": "9",
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"typeId": 5
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"difficulty": 2,
"dislikes": 8,
"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.",
"highlights": [],
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"dose": "2.5",
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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?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
"userPoint": null
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173,468,126 | false | 34 | null | 6,495,254 | null | false | [] | null | 6,926 | {
"__typename": "QuestionQA",
"choices": [],
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"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
"files": null,
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"typeId": 5
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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.",
"highlights": [],
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"question": "A 25-year-old patient is brought to the Emergency Department after overdosing on paracetamol. A paracetamol level is taken which is shown to be above the treatment line of the nomogram. N-acetylcysteine is prescribed at a dose of 150mg/kg over 1 hour, which is to be given in a 200mL intravenous infusion of 5% dextrose. Her weight is estimated to be 60kg.\n\n\nWhat is the concentration of (in milligrams per millilitre) of the N-acetylcysteine infusion?",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 2,
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"comment": "so lost on this one",
"createdAt": 1675185044,
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"comment": "this part, '0.11mmol is equivalent to 0.5mL of calcium gluconate 10%' is confusing and needs to be a bit more specific - 0.11 mmol of what?",
"createdAt": 1675339168,
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"comment": "the substance the question is about.. calcium gluconate ??",
"createdAt": 1738144218,
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"comment": "what",
"createdAt": 1676201340,
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"comment": "Nahhh I ain't a pharmacist",
"createdAt": 1703611903,
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"comment": "you'll be hearing from my lawyers quesmed ",
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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": "0.5mL of calcium gluconate 10% = 0.11mmol\n\n100mL of calcium gluconate 10% = 22mmol\n\nNow, after diluting 100mL of calcium gluconate 10% in 1 litre of glucose 5%, the total volume is: 100mL + 1L = 1100mL. Since the rate at which the solution is to be given is 50mL/hour, the total amount of time for the volume of 1.1L solution to be infused is: 1100mL ÷ 50ml/hour = 22 hours\n\nTherefore, the dose of calcium gluconate being given is: 22mmol ÷ 22 hours = 1mmol/hour.",
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"question": "A 71-year-old patient is noted to have a severely low corrected calcium level of 1.6mmol/L (normal range 2.2-2.6 mmol/L). As part of emergency management, he has already been given 10mL of 10% calcium gluconate infusion. To prevent recurrence, he is prescribed a further 100mL of calcium gluconate 10% diluted in 1 litre of glucose 5% to be given at 50mL/ hour. 0.11mmol is equivalent to 0.5mL of calcium gluconate 10%.\n\n\n\n\nBased on the information given above, what is the rate at which calcium gluconate is given (in mmol per hour)?",
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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": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "This faces a 25% reduction due to his renal impairment:\n\n(800/100) x 75 = 600mg per dose\n\nThis 600mg is given in a 5ml injection.\n\nSo the amount given in 1ml = 600/5 = 120mg per 1 ml",
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"comment": "The shortest safest time would have to round up to 30 minutes",
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"comment": "Why was mine marked wrong when i answered 29.2",
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"comment": "you need to round up to nearest min as per the question ",
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"comment": "why do we need to round up??? it just says round to the nearest min and the nearest min is 29mins",
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"comment": "you need to round up with time, as the minimum you need is 29.2 minutes, if you did 29.2 minutes that wouldn't be enough time for the infusion, therefore with time always round up. It's the same principle with vials that can only be used once. ",
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"comment": "so confused",
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"comment": "basically you have 0.2 minutes left over, so you need to round up to the next minute - it was a weird q for sure",
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"explanation": "Dose = 20 x 73 = 1460 mg\nTime = 1460 mg / 50 mg/min = 29.2 minutes\n\nThis is then rounded **up** to 30 minutes, as 29 minutes would not be able to deliver the total dosage required.",
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"__typename": "QuestionChoice",
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"comment": "Risperidone is usually given to avoid galactorrhea though? Even on the BNF it isn't listed as a S/E?",
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"comment": "idk which BNF youre reading but mine defo has galactorrhea \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 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.",
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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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"demo": null,
"entitlement": null,
"id": "2793",
"name": "Spironolactone side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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"userChapter": null,
"userNote": null,
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"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "6861",
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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 |
173,468,133 | false | 41 | null | 6,495,254 | 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": 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
},
{
"__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
}
],
"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,
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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
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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2797",
"name": "Statin side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
"totalCards": 2,
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"userNote": null,
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"conditions": [],
"difficulty": 3,
"dislikes": 7,
"explanation": null,
"highlights": [],
"id": "6865",
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"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 |
173,468,134 | false | 42 | null | 6,495,254 | null | false | [] | null | 6,868 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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
}
],
"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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"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 |
173,468,135 | false | 43 | null | 6,495,254 | null | false | [] | null | 6,870 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is not known to interact with lithium to cause hypokalaemia",
"id": "34297",
"label": "c",
"name": "Metformin hydrochloride 500 mg PO TDS",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Indapamide is a thiazide-like diuretic that is used in the treatment of hypertension. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. It is important to note that it can cause hypokalaemia when given with lithium, thus potentially increasing the risk of torsade de pointes",
"id": "34295",
"label": "a",
"name": "Indapamide 2.5 mg PO daily in the morning",
"picture": null,
"votes": 3903
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Captopril can increase the concentration of lithium but is not known to interact with lithium to cause hypokalaemia. Angiotensin-converting-enzyme inhibitors like captopril are known to cause hyperkalaemia",
"id": "34298",
"label": "d",
"name": "Captopril 75 mg PO BD",
"picture": null,
"votes": 724
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine is not known to interact with lithium to cause hypokalaemia",
"id": "34296",
"label": "b",
"name": "Amlodipine 10 mg PO OD",
"picture": null,
"votes": 14
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is not known to interact with lithium to cause hypokalaemia",
"id": "34299",
"label": "e",
"name": "Simvastatin 40 mg PO ON",
"picture": null,
"votes": 28
}
],
"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": "2802",
"name": "Lithium side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
},
"topicId": 90,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"conceptId": 2802,
"conditions": [],
"difficulty": 1,
"dislikes": 3,
"explanation": null,
"highlights": [],
"id": "6870",
"isLikedByMe": 0,
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"likes": 0,
"multiAnswer": null,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case presentation: A 50-year-old woman visits her GP for medication review \n\n\nPMH: Bipolar disoder, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia\nDH: Her current regular prescriptions, in addition to lithium carbonate 600 mg PO twice daily, are listed in the options below\nInvestigations:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|3.2 mmol/L|3.5 - 5.3|\n|Urea|5 mmol/L|2.5 - 7.8|\n|Creatinine|120 µmol/L|60 - 120|\n|Thyroid Stimulating Hormone|2.5 mU/L|0.3 - 4.2|\n|Total T4|120 nmol/L|60 - 150|\n\n\nQuestion: Select the prescription that is most likely to interact with lithium carbonate to cause the abnormal blood test results?",
"sbaAnswer": [
"a"
],
"totalVotes": 4676,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,136 | false | 44 | null | 6,495,254 | null | false | [] | null | 10,128 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause renal impairment.",
"id": "50370",
"label": "b",
"name": "Atorvastatin",
"picture": null,
"votes": 108
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salmeterol does not commonly cause renal impairment.",
"id": "50371",
"label": "c",
"name": "Salmeterol",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause renal impairment. It can sometimes cause renal impairment if taken as an overdose, however in this scenario the patient has not taken an overdose.",
"id": "50373",
"label": "e",
"name": "Paracetamol",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Tiotropium does not commonly cause renal impairment.",
"id": "50372",
"label": "d",
"name": "Tiotropium",
"picture": null,
"votes": 58
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Losartan is a cause of renal acute kidney injury. It alters the vascular tone of both the afferent and efferent arterioles. In turn, the blood flowing across the glomerulus is altered. This then reduces the glomerular filtration rate which causes a reduction in renal function.",
"id": "50369",
"label": "a",
"name": "Losartan",
"picture": null,
"votes": 2921
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3657",
"name": "The use of losartan is linked to acute kidney injury",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
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"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10128",
"isLikedByMe": null,
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"likes": 0,
"multiAnswer": null,
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"psaSectionId": 6,
"qaAnswer": null,
"question": "Case Presentation: A 64-year-old gentleman is admitted to AMU with leg pain.\n\n\n\n\n **PH** Hypertension, COPD, Hypercholesterolaemia\n\n\n **DH** Atorvastatin 20mg PO daily, Losartan 100mg PO daily, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH daily, Paracetamol 1g PO QDS\n\n\n **On examination**\n\n\nBP 142/82mmHg, HR 82, RR 12, Weight 80kg\n\n\n **Investigation**\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|4.3 mmol/L|3.5 - 5.3|\n|Urea|8.0 mmol/L|2.5 - 7.8|\n|Creatinine|182 µmol/L|60 - 120|\n|eGFR|48 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion: Select the medication that is most likely to have contributed to the reduction in renal function.",
"sbaAnswer": [
"a"
],
"totalVotes": 3099,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,137 | false | 45 | null | 6,495,254 | null | false | [] | null | 10,133 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol does not commonly cause constipation.",
"id": "50396",
"label": "c",
"name": "Salbutamol 200micrograms INH QDS",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydroxychloroquine does not commonly cause constipation.",
"id": "50397",
"label": "d",
"name": "Hydroxychloroquine 200mg PO OD",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Ferrous sulfate commonly causes constipation. The mechanism by which iron supplementation causes constipation is unclear. It is thought to either be through interactions with the gut flora or through facilitating the movement of water from the lower GI system via an osmotic gradient which in turn causes stool hardening and constipation.",
"id": "50394",
"label": "a",
"name": "Ferrous sulfate 200mg PO BD",
"picture": null,
"votes": 2824
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cetirizine is not known to cause constipation.",
"id": "50395",
"label": "b",
"name": "Cetirizine 10mg PO OD",
"picture": null,
"votes": 204
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen can cause constipation, however this is listed as a rare/very rare side effect whereas ferrous sulfate has constipation listed as a common side effect.",
"id": "50398",
"label": "e",
"name": "Ibuprofen 200mg PO QDS",
"picture": null,
"votes": 81
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3662",
"name": "Ferrous sulfate commonly causes constipation",
"status": null,
"topic": {
"__typename": "Topic",
"id": "130",
"name": "Geriatrics",
"typeId": 5
},
"topicId": 130,
"totalCards": null,
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"userChapter": null,
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"dislikes": 5,
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"id": "10133",
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"psaSectionId": 6,
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"question": "Case Presentation: A 68-year-old female attends her GP complaining of constipation. Her regular medicines are listed (below). Weight 50kg.\n\n\n**PH** Hayfever, COPD, iron deficiency anaemia, Systemic lupus erythematosus\n\n**DH** Cetirizine 10mg PO OD, Salbutamol 200micrograms INH QDS, Ferrous sulfate 200mg PO BD, Hydroxychloroquine 200mg PO OD, Ibuprofen 200mg PO QDS\n\nQuestion: Select the medication that is most likely to have contributed to this patient's constipation",
"sbaAnswer": [
"a"
],
"totalVotes": 3118,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,138 | false | 46 | null | 6,495,254 | null | false | [] | null | 18,107 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This is most likely an anaphylactic reaction to this child's first exposure to a penicillin antibiotic. The child is showing respiratory distress and circulatory dysfunction and require urgent treatment with adrenaline. In children aged 6-12 years, the recommended dose is 300 micrograms and it is given intramuscularly.",
"id": "10028522",
"label": "a",
"name": "Adrenaline 300 micrograms IM STAT",
"picture": null,
"votes": 1524
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the correct drug and dose however adrenaline should be given intramuscularly in this circumstance. It can be given intravenously by specialists however the dose for this is 1 microgram/kg.",
"id": "10028523",
"label": "b",
"name": "Adrenaline 300 micrograms IV STAT",
"picture": null,
"votes": 48
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the correct drug and route however it should be in *micrograms* not *milligrams*.",
"id": "10028524",
"label": "c",
"name": "Adrenaline 300 milligrams IM STAT",
"picture": null,
"votes": 106
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the correct dose for children >12 and adults.",
"id": "10028526",
"label": "e",
"name": "Adrenaline 500 micrograms IM STAT",
"picture": null,
"votes": 328
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is the correct dose for children younger than 6 years of age.",
"id": "10028525",
"label": "d",
"name": "Adrenaline 150 micrograms IM STAT",
"picture": null,
"votes": 36
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": null,
"files": null,
"highlights": [],
"id": "2693",
"pictures": [],
"typeId": 7
},
"chapterId": 2693,
"demo": null,
"entitlement": null,
"id": "6082",
"name": "Anaphylaxis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "161",
"name": "Emergency Medicine",
"typeId": 5
},
"topicId": 161,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
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"conceptId": 6082,
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"dislikes": 2,
"explanation": null,
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"multiAnswer": null,
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"qaAnswer": null,
"question": "Case Presentation: A 7-year-old boy in the emergency department collapses after being given oral amoxicillin.\r\n\n\n\n**On examination** Wheezy and breathless. CRT 3s, HR 101/min, BP 70/50 mmHg\n\nQuestion: Select the most appropriate option for management of this adverse treatment reaction.",
"sbaAnswer": [
"a"
],
"totalVotes": 2042,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,139 | false | 47 | null | 6,495,254 | 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
},
{
"__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
},
{
"__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": 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
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where is this mentioned in the BNF?",
"createdAt": 1705946039,
"dislikes": 0,
"id": "39592",
"isLikedByMe": 0,
"likes": 0,
"parentId": null,
"questionId": 6879,
"replies": [
{
"__typename": "QuestionComment",
"comment": "If you look in the 'Caution' section of Digoxin",
"createdAt": 1706092483,
"dislikes": 0,
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"id": 27393
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"displayName": "Myopathy DNA",
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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": "2811",
"name": "Hypokalaemia 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": []
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"conceptId": 2811,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
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"likes": 0,
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"psaSectionId": 7,
"qaAnswer": null,
"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"
],
"totalVotes": 5337,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,140 | false | 48 | null | 6,495,254 | null | false | [] | null | 6,880 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be useful as a baseline as aminophylline is metabolised hepatically. However routine monitoring is not necessary",
"id": "34347",
"label": "c",
"name": "Liver function tests",
"picture": null,
"votes": 424
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is at risk of hypokalaemia due to repeated salbutamol nebulisers and commencement of an aminophylline infusion. Renal function should be monitored",
"id": "34345",
"label": "a",
"name": "Urea and electrolytes",
"picture": null,
"votes": 3540
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intravenous magnesium is commonly given for severe acute exacerbations of asthma and levels may be monitored during treatment. However it is not being used here",
"id": "34349",
"label": "e",
"name": "Serum magnesium",
"picture": null,
"votes": 137
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a useful marker of beneficial effects of the treatment rather than adverse effects",
"id": "34348",
"label": "d",
"name": "Respiratory rate",
"picture": null,
"votes": 602
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be a useful marker of beneficial effects of the treatment rather than adverse effects",
"id": "34346",
"label": "b",
"name": "Bedside spirometry",
"picture": null,
"votes": 193
}
],
"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": "2812",
"name": "Aminophylline side effects",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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"highlights": [],
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"qaAnswer": null,
"question": "Case Presentation: A 19 year old man presents to A&E with chest pain and shortness of breath. **PMH** asthma, has had 3x previous A&E attendances for acute exacerbations and 1x hospitalisation stay. **DH** salbutamol 200 micrograms inhaler PRN, beclomethasone with formoterol (Fostair NEXThaler) 100/6 micrograms powder inhaler 2 puffs BD. Allergic to pollen and cat fur – exacerbates asthma.\n\n\n**O/E**\n\nVisibly short of breath with tripoding and use of accessory neck muscles. Sweaty. Peripherals warm and well-perfused. HR 103, RR 29, BP 129/68, O2 100% 15L reservoir mask. Widespread polyphonic wheeze on chest auscultation.\n\n**Investigations**\n\nCXR: No consolidation or pneumothoraces\n\nPEFR: 45% of normal predicted value\n\nHe has been given back to back salbutamol and ipratropium nebulisers and is being started on an aminophylline infusion.\n\nQuestion: Select the most appropriate option to monitor for adverse effects of this treatment.",
"sbaAnswer": [
"a"
],
"totalVotes": 4896,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,141 | false | 49 | null | 6,495,254 | null | false | [] | null | 6,886 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__typename": "QuestionChoice",
"answer": false,
"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": 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": 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 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
}
],
"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": "2818",
"name": "Methylphenidate monitoring",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 2818,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "6886",
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"likes": 0,
"multiAnswer": null,
"pictures": [],
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"psaSectionId": 7,
"qaAnswer": null,
"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"
],
"totalVotes": 5282,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,142 | false | 50 | null | 6,495,254 | 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": 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
},
{
"__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
}
],
"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": "2820",
"name": "Asthma",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"difficulty": 1,
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"qaAnswer": null,
"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 |
173,468,143 | false | 51 | null | 6,495,254 | null | false | [] | null | 6,894 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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": "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
},
{
"__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": "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": 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
}
],
"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,
"parentId": null,
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"__typename": "User",
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"displayName": "Epidermis Benign",
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"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"id": "2826",
"name": "Termination of Pregnancy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
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"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 |
173,468,144 | false | 52 | null | 6,495,254 | null | false | [] | null | 10,085 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this. An ultrasound of the liver would not be involved in the routine monitoring of allopurinol therapy.",
"id": "50190",
"label": "e",
"name": "Ultrasound of liver at 6 months",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Serum urate level is used in the first few weeks of allopurinol therapy in order to guide dosing, however, it would not be useful in monitoring the adverse effects of the drug.",
"id": "50187",
"label": "b",
"name": "Serum urate levels monthly",
"picture": null,
"votes": 439
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Signs of gout may be able to be seen on X-ray, however, they are not routinely repeated in the long-term management of gout. X-ray findings of gout include tophi (soft tissue deposits of urate) and punched-out erosions.",
"id": "50188",
"label": "c",
"name": "Repeat X-Ray of left toe in 6 months",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this.",
"id": "50186",
"label": "a",
"name": "LFTs every 3 months for the first year",
"picture": null,
"votes": 2610
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Foods rich in purines such as offal, oily fish, game and red meat can increase the risk of gout. These should be avoided/reduced in the management of gout. Patients' diets are not routinely monitored. A healthy, balanced diet, rich in fruit and vegetables is encouraged.",
"id": "50189",
"label": "d",
"name": "Food diary",
"picture": null,
"votes": 61
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Where is this mentioned in the BNF?\n",
"createdAt": 1705600679,
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"__typename": "QuestionComment",
"comment": "Under Hepatic impairment - \"Manufacturer advises monitor liver function periodically during early stages of therapy.\"",
"createdAt": 1705943067,
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"__typename": "QuestionComment",
"comment": "yeah but replying to above comment its UNDER hepatic impairment AKA people who have liver problems to begin with - this man doesnt",
"createdAt": 1737678474,
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"explanation": "Co-adminstration of allopurinol and azathioprine can lead to reduction in white blood cell count (pancytopenia) which can be very serious due to the high risk of infection. \n\nAllopurinol is a xanthine oxidase inhibitor used to treat chronic gout. \n\nXanthine oxidase is an enzyme that is also a part of the pathway that breaks down Azathioprine. \n\nWithout xanthine oxidase, azathioprine is broken down using a different pathway leading to accumulation of toxic metabolites that interfere with DNA synthesis and subsequent creation of white blood cells. Therefore, patients can present with pancytopenia, leading to higher risk of infection due to immunosuppresion.",
"files": null,
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"name": "Co-adminstration of allopurinol and azathioprine",
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"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"question": "Case Presentation: A 42-year-old man is due to be started on Allopurinol following a diagnosis of Gout in his left great toe. \n\n\n**PMH**\n\n* Type 1 Diabetes\n* Depression\n\n**DH**\n\n* Citalopram 40mg OD\n* Humulin M3 12 units BD\n\nQuestion: Which of the following is the most appropriate monitoring for the adverse effects of Allopurinol?",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,145 | false | 53 | null | 6,495,254 | null | false | [] | null | 10,134 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Impaired hepatic function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.",
"id": "50402",
"label": "d",
"name": "Liver function tests",
"picture": null,
"votes": 62
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydroxychloroquine can cause a range of haematological disorders such as agranulocytosis, leucopenia and thrombocytopenia. The frequency of these side effects occurring however is unknown, therefore monitoring for them is not recommended.",
"id": "50400",
"label": "b",
"name": "Full blood count",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Impaired renal function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.",
"id": "50401",
"label": "c",
"name": "Renal function",
"picture": null,
"votes": 249
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug",
"id": "50403",
"label": "e",
"name": "Troponin",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Retinopathy is a common side effect of hydroxychloroquine. It is important to ensure that there are no pre-existing issues with the retina prior to starting hydroxychloroquine due to the increased risk of worsening these pre-existing issues. Annual monitoring of the retina is initiated following 5 years of treatment (it can be started earlier if there is an increased risk of retinopathy).",
"id": "50399",
"label": "a",
"name": "Fundus photograph and Optical Coherence Tomography (OCT)",
"picture": null,
"votes": 2742
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
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"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3663",
"name": "Taking hydroxychloroquine requires ophthalmological monitoring due to the increased risk of retinal toxicity",
"status": null,
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"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"qaAnswer": null,
"question": "Case Presentation: A 34-year-old woman is referred to rheumatology due to ongoing joint pain and facial rashes. \n\n\n**PMH** Nil\n\n**DH** NKDA. Ibuprofen 200mg PO QDS\n\n**SH** smokes 10 cigarettes a day (5 pack year history)\n\n**Investigations**\n\nAnti-CCP antibodies: -ve\n\nANA: +ve\n\nAnti dsDNA antibodies: +ve\n\nRheumatoid factor: -ve\n\nBased on her symptoms and blood results, she is diagnosed with systemic lupus erythematosus and the decision is made to start hydroxychloroquine sulfate.\n\nQuestion: Select the most appropriate monitoring option required before initiating hydroxychloroquine sulfate.",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,468,146 | false | 54 | null | 6,495,254 | null | false | [] | null | 10,137 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring of prothrombin concentration is required with apixaban use.",
"id": "50418",
"label": "e",
"name": "Prothrombin",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring of factor V is required with apixaban use.",
"id": "50417",
"label": "d",
"name": "Factor V",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring is required with apixaban use. Factor Xa is the clotting protein that apixaban inhibits, it does not need to be monitored.",
"id": "50416",
"label": "c",
"name": "Factor Xa",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "No routine monitoring is required with apixaban use. INR would be monitored in patients taking warfarin.",
"id": "50415",
"label": "b",
"name": "INR",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "No routine monitoring is required with apixaban use. This is because direct oral anticoagulants have a predictable pharmacokinetic and pharmacodynamic response when given at a set dose, unlike warfarin for example which has a higher degree of unpredictability.",
"id": "50414",
"label": "a",
"name": "No routine monitoring required",
"picture": null,
"votes": 3041
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"demo": null,
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"name": "Patients taking apixaban (DOACs) require no routine monitoring of their clotting factors",
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"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
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"topicId": 74,
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"question": "Case Presentation: A 64-year-old gentleman is discharged from hospital following a diagnosis of atrial fibrillation. \n\n\n**PMH** Hypertension, Type 2 diabetes mellitus, Atrial fibrillation\n\n**DH** Ramipril 10mg PO OD, Metformin 500mg PO BD, Atenolol 50mg PO OD, Apixaban 5mg PO BD\n\nBoth the atenolol and apixaban are new prescriptions.\n\nQuestion: What routine monitoring is required for his new apixaban prescription?",
"sbaAnswer": [
"a"
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173,468,147 | false | 55 | null | 6,495,254 | null | false | [] | null | 6,899 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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": 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": "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": "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
}
],
"comments": [
{
"__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,
"dislikes": 0,
"id": "40023",
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"__typename": "QuestionComment",
"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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"__typename": "QuestionComment",
"comment": "Where can you find the gentamicin normogram",
"createdAt": 1709112329,
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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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"chapterId": 2618,
"demo": null,
"entitlement": null,
"id": "2831",
"name": "Gentamicin monitoring",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
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"question": "Case Presentation:\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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"typeId": 1,
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173,468,148 | false | 56 | null | 6,495,254 | null | false | [] | null | 6,909 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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": 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": "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
},
{
"__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": "34493",
"label": "d",
"name": "Start bisoprolol fumarate 5mg PO OD",
"picture": null,
"votes": 445
}
],
"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",
"createdAt": 1646752859,
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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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173,468,149 | false | 57 | null | 6,495,254 | 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
},
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"__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": "The recommended increment in levothyroxine is a gradual increment of 25-50 micrograms every 3-4 weeks",
"id": "34502",
"label": "c",
"name": "Increase levothyroxine sodium to 175 micrograms PO daily",
"picture": null,
"votes": 109
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "His thyroid function test suggest inadequate replacement and hence his medication should be increased and not decreased",
"id": "34501",
"label": "b",
"name": "Decrease levothyroxine sodium to 75 micrograms PO daily",
"picture": null,
"votes": 232
},
{
"__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
}
],
"comments": [],
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation:\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.",
"sbaAnswer": [
"a"
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173,468,150 | false | 58 | null | 6,495,254 | null | false | [] | null | 10,089 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5.",
"id": "50206",
"label": "a",
"name": "Stop warfarin and give phytomenadione (vitamin K) by slow intravenous injection Restart warfarin when INR is less than 5",
"picture": null,
"votes": 2166
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has an INR out of the target range and has experienced a minor bleeding episode. Withholding 1-2 doses of Warfarin may be appropriate if this patient had an INR of 6.5 but no evidence of bleeding. As this patient has experienced some bleeding, treatment with vitamin K is recommended.",
"id": "50208",
"label": "c",
"name": "Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose",
"picture": null,
"votes": 451
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has an INR out of the target range and has experienced a minor bleeding episode. Oral vitamin K should be given when INR is greater than 8 and there is no evidence of bleeding.",
"id": "50207",
"label": "b",
"name": "Stop warfarin and give phytomenadione (vitamin K) orally",
"picture": null,
"votes": 396
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5. Dried prothrombin complex concentrate or fresh frozen plasma would be appropriate where a severe bleeding episode has occurred.",
"id": "50209",
"label": "d",
"name": "Stop warfarin, give urgent intravenous treatment with phytomenadione (vitamin K) and dried prothrombin complex concentrate (factors II, VII, IX, and X), or fresh frozen plasma if the dried prothrombin complex is unavailable",
"picture": null,
"votes": 124
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. If INR is consistently raised, a decrease in dose may be appropriate but is not the most important next step.",
"id": "50210",
"label": "e",
"name": "Decrease Warfarin dose to 5mg",
"picture": null,
"votes": 9
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "he's not bleeding though so why would we not just withhold the warfarin for a couple doses like it says to in the bnf",
"createdAt": 1708602472,
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"comment": "exactly my thoughts, ButtMuncher.",
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"comment": "He's stopped bleeding?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 86-year-old female patient attends A&E with epistaxis, this has stopped within 30 minutes after nasal packing. She takes Warfarin for atrial fibrillation. \n\n\n**PMH**\n\n* Atrial fibrillation\n* Aortic Stenosis\n* Psoriasis\n* Psoriatic Arthritis\n\n**DH**\n\n* Warfarin 6mg OD\n* Hydromol intensive cream QDS\n* Paracetamol 1g QDS\n\n**On Examination**\n\n* HR 78bpm\n* Blood pressure 124/80 mm/Hg\n* Oxygen saturation 96%\n* RR 16\n* Temperature 36.8\n\n**Investigations**\n\n* INR: 6.5\n* Target INR: 2-3\n\nQuestion: Given the results of the above investigation, what is the most appropriate next step?",
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173,468,151 | false | 59 | null | 6,495,254 | null | false | [] | null | 10,091 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.",
"id": "50216",
"label": "a",
"name": "Don't change his treatment",
"picture": null,
"votes": 1672
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.",
"id": "50217",
"label": "b",
"name": "Stop his ramipril now",
"picture": null,
"votes": 11
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.",
"id": "50219",
"label": "d",
"name": "Switch him to amlodipine",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no indication to increase this gentleman's ramipril dose as his blood pressure reading isn't too high.",
"id": "50218",
"label": "c",
"name": "Increase ramipril to 10mg PO OD",
"picture": null,
"votes": 1334
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.",
"id": "50220",
"label": "e",
"name": "Switch him to candesartan",
"picture": null,
"votes": 62
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "In the question his potassium has gone down from 4.4 to 3.6 - so it is not raised? Your answer comment doesn't correlate with the question!",
"createdAt": 1675364926,
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"comment": "isn't the BP still hypertensive so why wouldn't you increase ramipril to get a better contrl of his BP",
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"comment": "increased by 1 in the clinic setting ",
"createdAt": 1706617508,
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"comment": "I get that his BP could be slightly raised due to the white coat effect, but given this is an exam where you have to follow BNF guidelines closely, the 141/82 reading is unnecessarily confusing. The cutoff for hypertension treatment targets is 140/90 in a patient under 80 years old. If you want to write the question to imply the patient's BP is well-controlled, why not just say his BP is 139/82?? ",
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"comment": "mashallah Brether?Sester?\n",
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"comment": "agree so much",
"createdAt": 1737907120,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 49-year-old gentleman is attends his GP for a review of his blood pressure medication. \n\n\n\n\n **PMH**\nHypertension\n\n\n **DH**\nRamipril 5mg PO OD.\n\n\n **Investigations**\nToday's bloods:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|141 mmol/L|135 - 145|\n|Potassium|3.6 mmol/L|3.5 - 5.3|\n|Urea|3.4 mmol/L|2.5 - 7.8|\n|Creatinine|66 µmol/L|60 - 120|\n\n\n\nBloods from 3 months ago:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|139 mmol/L|135 - 145|\n|Potassium|4.4 mmol/L|3.5 - 5.3|\n|Urea|3.6 mmol/L|2.5 - 7.8|\n|Creatinine|71 µmol/L|60 - 120|\n\n\nToday's blood pressure: 141/82 mmHg\n\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
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173,468,152 | false | 60 | null | 6,495,254 | null | false | [] | null | 18,114 | {
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"explanation": "Due to this patient's renal impairment, intravenous co-amoxiclav should be given every 12 hours, not every 8 hours.",
"id": "10028561",
"label": "e",
"name": "Co-amoxiclav 1.2g IV every 8 hours",
"picture": null,
"votes": 600
},
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"question": "Case Presentation:\n\n\n\n\nAn 83-year-old woman is on the Senior Health ward for treatment of delirium secondary to a urinary tract infection.\n\n\n **On Examination**\nBP 121/82 mmHg, HR 80/min and regular, RR 10/min, Temperature 37.3 C. O2 sats 99% RA.\n\n\n **Investigations**\nUrine dipstick: +++ leucocytes and nitrates\n\n\nUrine MCS\n\n\nR Nitrofurantoin\n\n\nR Trimethoprim\n\n\nS Co-Amoxiclav\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|135 mmol/L|135 - 145|\n|Potassium|4.6 mmol/L|3.5 - 5.3|\n|Urea|10.5 mmol/L|2.5 - 7.8|\n|creatinine clearance |25 mL/minute|100-150 ml/min|\n|eGFR|28 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nQuestion:\nSelect the most appropriate decision option with regard to the management of her infection based on these data.",
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"explanation": "# Summary\n \nAcute pulmonary oedema refers to fluid accumulation in the interstitium and alveoli of the lungs, which may be cardiogenic or non-cardiogenic. Symptoms include severe dyspnoea, diaphoresis, paroxysmal noctural dyspnoea, orthopnoea and a cough classically productive of pink frothy sputum. Key investigations include a chest X-ray for diagnosis, an ABG, ECG basic bloods including a troponin and BNP and an echocardiogram. Management involves giving oxygen, IV Furosemide and consider non-invasive or invasive ventilation in patients not responding to treatment.\n \n# Definition\n \nAcute pulmonary oedema is a condition that occurs when excess fluid accumulates in the lungs, particularly within the pulmonary interstitium and alveoli.\n \n# Aetiology\n \nPulmonary oedema can be divided into two main groups: cardiogenic and non-cardiogenic.\n\nCardiogenic pulmonary oedema is associated with raised pulmonary capillary pressures, with the following causes:\n\n- Acute coronary syndrome\n- Decompensation of chronic heart failure (e.g. stopping diuretics, infection, volume overload)\n- Valvular disorders (e.g. acute mitral regurgitation)\n- Acute arrhythmia\n- Acute myopathies (e.g. myocarditis, postpartum cardiomyopathy)\n- Medications e.g. NSAIDs\n- Hypertensive crisis\n\nNon-cardiogenic causes of pulmonary oedema include:\n\n- Acute respiratory distress syndrome\n- Renal artery stenosis\n- Acute kidney injury\n- Iatrogenic fluid overload\n- High altitude\n- Neurogenic pulmonary oedema (e.g. secondary to head injury)\n\n# Signs and Symptoms\n \n**Symptoms include:**\n\n- Severe dyspnoea\n- Orthopnoea\n- Paroxysmal nocturnal dyspnoea (PND)\n- Anxiety\n- Diaphoresis\n- Cough - may be dry or productive of pink frothy sputum\n- Nausea\n\n**On examination, signs include:**\n\n- Respiratory distress\n- Tachypnoea\n- Tachycardia\n- Raised jugular venous pressure (JVP)\n- Inspiratory crepitations on auscultation\n- Gallop rhythm (3rd heart sound)\n- Peripheral oedema and hepatomegaly if secondary to right heart failure\n- Hypotension and oliguria if in cardiogenic shock\n \n\n# Differential Diagnosis\n \n- **Acute exacerbation of chronic obstructive pulmonary disease**: also associated with dyspnoea and cough, usually productive of sputum and symptoms of orthopnoea and PND not present.\n- **Pneumonia**: also causes dyspnoea and cough, patients usually are febrile and may have other symptoms such as chest pain. Can be differentiated on chest X-ray (showing consolidation in pneumonia).\n- **Pulmonary embolism**: also causes sudden dyspnoea, may have haemoptysis and tachycardia. Risk factors e.g. immobility may be present, chest X-ray is typically normal but can co-exist with other pulmonary pathologies.\n\n# Investigations\n\n**Bedside tests:**\n\n- **ECG** to look for causes e.g. ischaemic changes in acute coronary syndrome or an arrhythmia, may show evidence of chronic heart failure e.g. left ventricular hypertrophy\n- **Arterial blood gas** to assess for respiratory failure which is usually type 1 unless consciousness is impaired in severe illness\n\n**Blood tests:**\n\n- **Full blood count** and **CRP** for inflammatory markers as infection may precipitate acute pulmonary oedema\n- **U&Es** and **LFTs** to look for renal or hepatic causes of pulmonary oedema, hyponatraemia may occur\n- **Troponin** to investigate for acute coronary syndrome\n- **BNP** which should be raised in heart failure\n\n**Imaging:**\n\n- **Chest X-ray** classically shows ABCDE signs of pulmonary oedema:\n - **A**lveolar opacification (bilateral perihilar lung shadowing)\n - Kerley **B** lines (thickened subpleural interlobular septa)\n - **C**ardiomegaly\n - Upper lobe **D**iversion\n - Pleural **E**ffusions\n- **Echocardiogram** to assess heart function and look for a cause e.g. valvular disease\n\n [lightgallery]\n \n\n# Management\n \nAn ABCDE approach should be taken and a medical emergency call put out if required:\n\n- **Airway**\n - Position the patient upright\n - Intubation may be required in some cases e.g. reduced GCS secondary to hypercapnia in patients who have tired\n- **Breathing**\n - Give high flow oxygen via a non-rebreather mask\n - Non-invasive ventilation (NIV) may be required e.g. in cases of severe dyspnoea and acidaemia\n- **Circulation**\n - Ensure the patient has adequate IV access\n - Give IV furosemide, usually in boluses of 20-40mg\n - Nitrates should not be used routinely\n - Inotropes or vasopressors may be required in cases of cardiogenic shock\n - Monitor input-output and consider a urinary catheter\n- **Disability**\n - Small doses of morphine may be required for agitation or chest pain but opiates should not be given routinely\n- **Exposure/Everything Else**\n - Review medications - beta-blockers should usually be continued unless the patient is bradycardic or shocked\n - Ensure cardiology are aware in cases of cardiogenic pulmonary oedema\n - Mechanical circulatory support (e.g. a ventricular assist device) is an option in acute severe heart failure \n \n# NICE Guidelines\n\n[NICE - Acute heart failure: diagnosis and management](https://www.nice.org.uk/guidance/cg187/)\n\n# References\n \n[Radiopaedia - Pulmonary Oedema](https://radiopaedia.org/articles/pulmonary-oedema-summary?lang=gb)\n\n[Patient UK - Acute Pulmonary Oedema](https://patient.info/doctor/acute-pulmonary-oedema)\n\n[RCEM Learning - Cardiogenic Pulmonary Oedema](https://www.rcemlearning.co.uk/reference/cardiogenic-pulmonary-oedema/)",
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"explanation": "# Drug choice feedback\n\nAdministration of furosemide, a loop diuretic, is the most appropriate treatment for this gentleman to alleviate his shortness of breath and peripheral oedema. It is an effective and inexpensive choice of diuretic.\n\n# Dose/Route/Frequency/Duration feedback\n\nThe correct dose is 20-50mg intravenously for adults. This can be increased in steps of 20mg every 2 hours if further treatment is required. Furosemide can be given orally or intramuscularly as well, although the intravenous route is preferred in hospital due to more rapid onset of action and it is given that a cannula is in situ.",
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"question": "Case Presentation: A 73-year-old gentleman is brought to the Emergency Department with shortness of breath and ankle swelling. He denies any chest pain.\n\n\n## PH\n\nIschaemic heart disease, Type 2 diabetes mellitus, Hyperlipidaemia\n\n## DH\n\nAspirin 75mg OD PO, Ramipril 5mg OD PO, Metformin 1g BD PO, Empaglifozin 10mg, Bisoprolol 2.5mg PO OD, Atorvastatin 80mg PO OD (NKDA)\n\n## On examination\n\nAppears distressed. CRT 3s, peripheries cool. Cannula in situ. Bilateral peripheral oedema up to the mid-shins. JVP seen just inferior to earlobe.\n\nTemperature 37.3°C, HR 110, RR 18, BP 156/68, O2 93% on 5L oxygen, GCS 14, Weight 79kg\n\n## Investigations\n\nFBC: Hb 152, WCC 5.3, Plts 311\n\nU&Es: Na<sup>+</sup> 141, K<sup>+</sup> 4.2, Cl<sup>-</sup> 102, Ur 10.5, Cr 105, eGFR 64mL/min/1.73m<sup>2</sup>\n\nECG: NSR and left ventricular strain\n\nCXR: cardiomegaly and interstitial oedema\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his shortness of breath and peripheral oedema.",
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"comment": "i gave 250 ml saline over 15 mins, would this be wrong? i just thought due to his older age and slightly lower eGFR? :/",
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"comment": "250ml fluid challenge is usually given in patients with heart failure as you don't want to overload them with too much fluid - not sure if this info is on BNF ",
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"comment": "in the actual PSA it has to be 10 because guidelines say <15m ",
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"explanation": "# Drug choice feedback\n\nThis patient requires urgent fluid resuscitation as part of the management for his wound sepsis. Crystalloid fluids such as 0.9% sodium chloride or Hartmann's solution are first-line in such cases.\n\n# Dose/Route/Frequency/Duration feedback\n\n500mL is the standard dose used for a fluid bolus ('fluid challenge') in resuscitation. Vital observations such as heart rate and blood pressure are monitored after each dose to see if a further bolus is required. Fluids can only be given intravenously; this route of administration also ensures the fastest response to be seen in the patient. A duration of 15 minutes or less for every 500mL is acceptable.",
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"question": "Case Presentation: A 68-year-old gentleman admitted to the general ward for observation after a right hemicolectomy 7 days ago is being treated for sepsis. He is found to be drowsy and confused.\n\n\n\n\n## PH\n\n\nColorectal cancer, Hyperlipidaemia, Gout\n\n\n## DH\n\n\nAtorvastatin 40mg PO ON, Allopurinol 300mg PO OD\n\n\n## On examination\n\n\nAppears delirious and not oriented to time and place. Peripheries warm, CRT 3s. HS I + II + 0, chest clear.\n\n\nTemperature 38.9°C, HR 96, RR 27, BP 95/65, O2 95% RA, GCS 13, Weight 75kg\n\n\n## Investigations\n\n\nFBC: Hb 148, WCC 15.5, Plts 420\n\n\nU&Es: Na<sup>+</sup> 141, K<sup>+</sup> 4.3, Cl<sup>-</sup> 98, Ur 9.2, Cr 110, eGFR 61mL/min/1.73m<sup>2</sup>\n\n\nBM: 6.7mmol/L (normal rnage 3.5-5.5 mmol/L)\n\n\n# Prescribing Request\n\n\nWrite a prescription for one fluid that is most appropriate for treating his current condition",
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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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"explanation": "# Summary\r\n\r\nStable angina, characterised by chest pain triggered by myocardial ischemia, is most commonly caused by coronary artery disease. Typical anginal chest pain is described as an exertional chest discomfort that may radiate to the jaw/neck/arm and that is alleviated by rest (<5 minutes) or with GTN spray. Diagnosis involves investigations such as ECG, blood tests, and CT coronary angiogram. Management includes conservative measures to optimise cardiovascular risk factors, medical treatment with anti-anginal medications, and revascularisation options like coronary artery bypass graft or percutaneous coronary intervention in cases not controlled by medical therapy.\r\n\r\n# Definition \r\n\r\nTypical anginal chest pain is defined by the following 3 features:\r\n\r\n1. Constriction/heavy discomfort to chest that may radiate to the jaw/neck/arm.\r\n2. Brought on by exertion.\r\n3. Alleviated by rest (<5 minutes) or GTN spray. \r\n\r\n3/3 features = typical angina pain \r\n\r\n2/3 features = atypical angina pain\r\n\r\n0-1/3 features = non-anginal pain \r\n\r\n# Epidemiology \r\n\r\nA 2020 Health Survey for England estimated prevalence in all UK adults as 3%, increasing to a prevalence of 10–12% in women aged 65–84 years and 12–14% in similarly aged men. \r\n\r\n# Pathophysiology\r\n\r\nStable angina occurs as a result of a mismatch of myocardial oxygen supply and demand. Most commonly, stable angina is due to coronary artery disease. Coronary artery disease refers to the narrowing of coronary arteries by atherosclerosis and plaque formation. When demand for myocardial oxygen increases with exertion, narrowed coronary arteries cannot meet this increased demand leading to myocardial ischaemia and pain. \r\n\r\nOther rarer causes of stable angina include anaemia, aortic stenosis, or hypertrophic cardiomyopathy.\r\n \r\n# Classification \r\n \r\nStable angina pain can be considered by its limitations on day-to-day activity:\r\n\r\n* Class I: no angina with normal physical activity. Strenuous activity may cause symptoms. \r\n* Class II: angina pain causes slight limitation on normal physical activity. \r\n* Class III: angina causes marked limitation on normal physical activity. \r\n* Class IV: angina occurs with any physical activity and may occur at rest (see unstable angina). \r\n\r\n# Symptoms and Signs\r\n\r\n* Central, constricting chest pain that radiates to neck/jaw/arm. \r\n* Exertional chest pain that is relieved on rest/GTN. \r\n* Associated symptoms: nausea, vomiting, clamminess or sweating. \r\n\r\nStable angina may have no clinical signs on examination at rest.\r\n\r\n# Differential Diagnoses \r\n\r\n* **Acute Coronary Syndrome (ACS)** \r\n\t* **Similarities**: cardiac-sounding chest pain as a presenting complaint for both. Similar patient profile with significant risk factors for coronary artery disease. \r\n\t* **Differences**: stable angina only occurs on exertion and is alleviated by rest. ACS chest pain occurs at rest. \r\n\r\n* **Gastro-oesophageal reflux disease (GORD)** \r\n\t* **Similarities**: both may present with central chest discomfort/pain. \r\n\t* **Differences**: discomfort in stable angina commonly described as a squeezing or pressure-like pain brought on by exertion. GORD-related chest discomfort often described as a burning sensation that is triggered by certain foods, alcohol, or lying down. \r\n\r\n* **Costochondritis** \r\n\t* **Similarities**: both present with chest pain. \r\n\t* **Differences**: costochondritis refers to inflammation of the cartilage connecting ribs to the sternum. The pain is described as sharp and can be reproduced by pressing on the chest wall. \r\n\r\n* **Pleuritic Chest Pain e.g. Pulmonary Embolism, Pneumonia** \r\n\t* **Similarities**: both present with chest pain or discomfort. \r\n\t* **Differences**: pleuritic chest pain is often described as sharp and worse on inspiration. Pleuritic chest pain will also be accompanied by clinical features relating to the underlying cause e.g. productive cough, fevers, risk factors for VTE, or a hot swollen calf. \r\n\r\nOther differential diagnoses include anxiety, aortic dissection (radiates to the back), and other causes of musculoskeletal chest pain. \r\n\r\n# Investigations\r\n\r\nOnce atypical/typical anginal pain is suspected: \r\n\r\n**Routine investigations in primary care**: \r\n\r\n* ECG - to assess for ischaemic changes or previous MI. \r\n* Bloods - FBC and TFTs (to exclude anaemia and hyperthyroidism respectively which can exacerbate angina symptoms).\r\n* Consider cardivascular risk factors: hypertension, hypercholesterolaemia, diabetes mellitus, smoking. \r\n\r\n**1st line investigations**\r\n\r\n* CT coronary angiogram (CT CA)- indicated if typical/atypical angina pain or if ECG shows ischaemic changes in chest pain with <2 angina features.\r\n\r\n**2nd line investigations** \r\n\r\nIf CTCA is inconclusive the patient may undergo functional imaging: \r\n\r\n* Stress echocardiogram \r\n* Myocardial perfusion SPECT \r\n* Cardiac MRI\r\n\r\n**3rd line investigations**\r\n\r\nInvasive coronary angiography can be performed if there are inconclusive results from non-invasive testing.\r\n\r\n# Management\r\n\r\n## Conservative management\r\n\r\nConservative management involves the optimisation of cardiovascular risk factors to reduce the atherosclerotic process. \r\n\r\n* Smoking cessation\r\n* Glycaemic control\r\n* Hypertension\r\n* Hyperlipidaemia\r\n* Weight loss\r\n* Alcohol intake \r\n\r\n## Medical management \r\n\r\n* Secondary prevention: aspirin 75mg OD and statin 80mg ON. \r\n* GTN spray for symptom relief: inform patient of side-effects (headache, flushing, dizziness) and to repeat dose if pain not stopped after 5 minutes. \r\n\r\n*Emergency help should be sought if pain not subsided after 2 doses of GTN as this may indicate acute coronary syndrome.* \r\n\r\n**Anti-anginal medications**\r\n\r\n**1st line** = beta-blocker (bisoprolol) OR calcium channel blocker (verapamil or diltiazem). *Do not combine due to risk of heart block*. \n\nIf taking a beta-blocker and symptoms are uncontrolled, switch to, or add, a long-acting dihydropyridine calcium-channel blocker (CCB), such as amlodipine, modified-release nifedipine. If taking a non-dyhydropyridine calcium channel blocker already, switch to a beta blocker.\r\n\r\nIf neither can be tolerated, consider a long-acting nitrate (ISMN), ivabradine, nicorandil or ranolazine. \r\n\r\n**2nd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker (amlodipine or nifedipine)\r\n\r\n**3rd line** = beta-blocker (bisoprolol) AND long-acting dihydropyridine calcium channel blocker AND long-acting nitrate.\r\n\r\nA 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. At this stage, revascularisation with PCI or CABG must be considered. \r\n\r\n## Revascularisation\r\n\r\nRevascularisation with coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) must be considered in patients with: \r\n\r\n* Symptoms which are not controlled by optimal medical management.\r\n* Complex 3 vessel disease and/or significant left main stem on CTCA. \r\n\r\n# NICE Guidelines\n\r\n[NICE Guidance on Cardiac-Sounding Chest Pain](<https://www.nice.org.uk/guidance/cg95/chapter/Recommendations>) \r\n\n[NICE Guidance on Stable Angina](<https://www.nice.org.uk/guidance/cg126/chapter/Guidance>) \r\n\r\n# References\r\n\r\n[Patient UK Information on Stable Angina](<https://patient.info/doctor/stable-angina-2>) ",
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"explanation": "## Drug choice feedback\n\nGlyceryl Trinitrate (GTN) is a vasodilator which works to relax the vascular smooth muscle of the coronary vessels to restore blood flow to the myocardium. It is the first-line drug in the treatment of the symptoms of angina. Calcium channel blockers and beta-blockers may help reduce the frequency of angina attacks but will not relieve the symptoms of an attack as rapidly as GTN.\n\n## Dose/Route/Frequency/Duration feedback\n\nGTN should be prescribed as 400-800 micrograms in the form of sublingual tablets or a sublingual spray. Tablets come in 500 or 600 micrograms. A single spray is 400 micrograms and up to two sprays may be given per dose. 400, 500, 600 and 800 micrograms are therefore all acceptable doses. Dosing can also be written as 1 tablet or 1-2 sprays. Route MUST be sublingual, NOT oral. GTN should be given as and when the patient is experiencing symptoms, or before an activity known to cause angina symptoms. The frequency of use is therefore PRN.",
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"question": "Case Presentation: A 56-year-old gentleman, attends GP surgery with 3 episodes of central crushing chest pain on exertion. These have come on twice whilst walking up some stairs and once after running for a bus. The pain during each episode subsided after around 2 minutes. \n\n\n\n## PMH\nHyperlipidaemia\nHypertension\nObesity\n\n## DH\nAtorvastatin\nAmlodipine\n\n## On examination\nHe looks well at rest.\n\nHR 90, RR 16, BP 134/92\n\n## Investigations\nECG is normal\n\n# Prescribing Request\n\nWrite a prescription for one drug to rapidly relieve the patient's symptoms.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,468,207 | false | 5 | null | 6,495,256 | null | false | [] | null | 10,056 | {
"__typename": "QuestionPrescription",
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"comments": [
{
"__typename": "QuestionComment",
"comment": "Why not dabigatran?",
"createdAt": 1706299912,
"dislikes": 0,
"id": "39918",
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"likes": 2,
"parentId": null,
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{
"__typename": "QuestionComment",
"comment": "They said they did not want a needle so not SC. ",
"createdAt": 1706473073,
"dislikes": 2,
"id": "40081",
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"questionId": 10056,
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"displayName": "Acute DNA",
"id": 28385
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"displayName": "Recessive Myopathy",
"id": 33967
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},
{
"__typename": "QuestionComment",
"comment": "There was no option for apixaban 2.5 mg tablets (it only showed 5 and 10 mg), and also frequency was fixed on \"daily\" so I couldn't change it to 'twice daily'",
"createdAt": 1736770028,
"dislikes": 0,
"id": "60436",
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"likes": 7,
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"questionId": 10056,
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"displayName": "Aortic Aneurysm",
"id": 77398
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"typeId": 2
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"demo": null,
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"id": "2693",
"name": "Post-Operative Thromboprophylaxis ",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
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"explanation": "## Drug choice feedback\n\nAs this patient is needle phobic, Low Molecular Weight Heparins (LMWHs) are not appropriate as these are delivered by subcutaneous injection. Alternatives include low-dose aspirin, Apixaban and Rivaroxaban.\n\nVenous thromboembolism (VTE) prophylaxis is a common topic for PSA questions. Make sure to read the details of the question carefully and use the BNF treatment summary guidance on venous thromboembolism prophylaxis carefully.\n\n## Dose/Route/Frequency/Duration feedback\n\nApixaban/Aspirin/Rivaroxaban should be given at a 2.5mg/75mg/10mg dose as an oral tablet for 10-14 days when given for VTE prophylaxis.",
"highlights": [],
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"label": "rivaroxaban 10 mg tablets",
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"label": "2 weeks",
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"label": "aspirin 75 mg tablets",
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"label": "2.5 mg",
"value": 439,
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"label": "apixaban 2.5 mg tablets",
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"qaAnswer": null,
"question": "Case Presentation: A 68-year-old female patient is on the orthopaedic ward after having an elective knee replacement for osteoarthritis. She is now 10 hours post-surgery. She is needle phobic and categorically refuses any further injections. \n\n\n\n\n## PH\nHypothyroidism\n\n\n## DH\nLevothyroxine 75mg OD\n\n\n## On examination\nThe patient looks well at rest.\n\n\nWeight 72kg\n\n\nHR 86, RR 18, BP 128/84, Temperature 36.8°C\n\n\n## Investigations\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|138 mmol/L|135 - 145|\n|Potassium|4.5 mmol/L|3.5 - 5.3|\n|Urea|5.0 mmol/L|2.5 - 7.8|\n|Creatinine|100 µmol/L|60 - 120|\n|eGFR|80 mL/min/1.73m<sup>2</sup>|> 60|\n\n\n# Prescribing Request\n\n\nWrite a prescription for one drug for prophylaxis of venous thromboembolism in this patient.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,468,208 | false | 6 | null | 6,495,256 | null | false | [] | null | 10,101 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Nice recommend - \"Arrange initial review after one week if the person is aged 18–25 years or there is a particular concern for risk of suicide, and ensure a risk management strategy is in place.\", all other patients are review in 2 weeks",
"createdAt": 1674729742,
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"displayName": "Odor Poisoning",
"id": 4808
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"__typename": "QuestionComment",
"comment": "would it be wrong if i wrote sertraline 25mg in medicine option",
"createdAt": 1734272871,
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{
"__typename": "QuestionComment",
"comment": "I think it would be wrong in the actual PSA as you can't cut tablets in half",
"createdAt": 1738071453,
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"id": "61759",
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"likes": 1,
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"displayName": "Syed",
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"displayName": "Kussmaul Sign",
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},
{
"__typename": "QuestionComment",
"comment": "how can you dose 50mg tablets at 25mg per dose ",
"createdAt": 1737581311,
"dislikes": 0,
"id": "61276",
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"likes": 8,
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "3630",
"name": "First line management of generalised anxiety disorder",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
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"difficulty": 1,
"dislikes": 9,
"explanation": "## Drug choice feedback\n\nThis gentleman has generalised anxiety disorder. They require pharmacological intervention alongside psychological intervention. The first line medication to treat generalised anxiety disorder is sertraline.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe first line treatment for this gentleman's anxiety is Sertraline 25mg PO OD. NICE advise: *if sertraline is ineffective,* offer an alternative SSRI, for example, paroxetine or escitalopram, or a selective serotonin-noradrenaline re-uptake inhibitor (SNRI), such as duloxetine or venlafaxine. \n\n\nInitially, 25 mg daily is prescribed for 1 week, then increased to 50 mg daily, then increased in steps of 50 mg at intervals of at least 1 week if required, increase only if response is partial and if drug is tolerated; maximum 200 mg per day.",
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"__typename": "PrescriptionAnswer",
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"question": "Case Presentation: A 24-year-old man attends his GP due to feelings of social anxiety. He has been struggling to sleep and is constantly worrying about university interactions with his tutor, his relationship and his friendships. He does not report any suicidal ideations or any plans to harm others. He has tried cognitive behavioural therapy but he feels it has not made much of a difference.\n\n\n## PH\nType 1 diabetes mellitus\n\n## DH\nHumulin I 10 units subcutaneous OD, actrapid 6 units subcutaneous BD (after breakfast and dinner). NKDA.\n\n## On examination\n\nHe appears low in mood, his speech is quiet and laboured. He doesn't particularly engage with the review.\n\nTemperature 36.4°C, HR 106, RR 19, BP 118/78, O<sub>2</sub> 99% RA, GCS 15, Weight 64kg\n\n## Investigations\n\nNil.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his anxiety.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
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} | MarksheetMark |
173,468,209 | false | 7 | null | 6,495,256 | null | false | [] | null | 18,093 | {
"__typename": "QuestionPrescription",
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"comments": [
{
"__typename": "QuestionComment",
"comment": "why is fluoxetine incorrect?\n",
"createdAt": 1737476670,
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"id": "61150",
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"displayName": "Suture Jargon",
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"comment": "starting sertraline dose in OCD is 50 mg not 25 mg, 25 is for anxiety disorders only\n\nObsessive-compulsive disorder\nBy mouth\nAdult\nInitially 50 mg once daily, then increased in steps of 50 mg at intervals of at least 1 week if required; maximum 200 mg per day.",
"createdAt": 1737990019,
"dislikes": 0,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "Yeah but it's asking for you to prescribe something for her anxiety ",
"createdAt": 1738001989,
"dislikes": 0,
"id": "61704",
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"likes": 1,
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"displayName": "Epidermis Benign",
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"displayName": "Vaccine Complement",
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{
"__typename": "QuestionComment",
"comment": "SSRI/SNRI contraindicated with NSAID = upper gi bleed ? ",
"createdAt": 1738006186,
"dislikes": 0,
"id": "61716",
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"likes": 3,
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"displayName": "Zika Hereditary",
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"name": "Anxiety, Obsessions and Stress Reactions (including OCD)",
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"typeId": 5
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"explanation": "# Drug choice feedback\n\nThis is a patient with known anxiety and OCD, who has already tried CBT and with ongoing symptoms. For these patients, the next line of treatment is medication, with selective serotonin reuptake inhibitors (SSRI) first line. There are several SSRIs which can be used, with sertraline and escitalopram very popular in the UK.\n\n# Dose/Route/Frequency/Duration feedback\n\nMost of these drugs can be uptitrated if the desired treatment effects are not being witnessed. 2nd line medication treatments include selective serotonin-noradrenaline re-uptake inhibitors (SNRI), such as duloxetine or venlafaxine. In patients younger than 30 years of age, when initiating SSRI therapy, a follow-up at 1 week should be arranged to review effectiveness and adverse effects as during this initial period there is an increased risk of worsening symptoms. ",
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"question": "Case Presentation: A 26-year-old woman presents to the GP complaining of worsening symptoms of anxiety including panic attacks. There has been increased stress due to her job as a corporate lawyer. She has previously tried CBT in the past and currently has private counselling sessions weekly.\n\n\n## PH\n\nAnxiety, OCD, Menorrhagia, Migraine\n\n## DH\n\nIbuprofen 400mg PO PRN\n\nNKDA\n\n## On examination\n\nNo cyanosis. Normal consciousness but mildly distressed and agitated. Good air entry bilaterally.\n\nTemperature 37.0°C, HR 90, RR 14, BP 110/68, O<sub>2</sub> saturation 96% RA, GCS 15, Weight 70kg\n\n## Investigations\n\nNone\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for managing this patient's worsening anxiety.\n",
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173,468,210 | false | 8 | null | 6,495,256 | null | false | [] | null | 18,094 | {
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"__typename": "QuestionComment",
"comment": "i'm a little confused. if paracetamol is ineffective then why not go up the pain ladder to co-codamol?",
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"comment": "Dysmenorrhoea is usually treated with NSAIDs rather than opioids. They usually provide better pain relief hence mefenamic acid is prescribed in endometriosis as well :)",
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"comment": "Hummm, Naproxen is prescribed as \"Initially 500 mg for 1 dose, then 250 mg every 6–8 hours as required\" according to the BNF for dysmenorrhea. ",
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"comment": "BNF states 3-4 times a day so why is QDS wrong?",
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"comment": "why is tranexamic acid not accepted",
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"comment": "for heavy bleeding, not pain ",
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"comment": "Why not ibuprofen 300mg?",
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"explanation": "# Drug choice feedback\n\nThis patient presents with symptoms of primary dysmenorrhoea. Management of this condition if simple analgesia such as paracetamol is ineffective involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs). If the patient does not wish to conceive, the combined oral contraceptive pill can also be considered, however this is not the case in the above scenario.\n\n# Dose/Route/Frequency/Duration feedback\n\nEach of these NSAIDs can be taken orally, and a short course has been prescribed so that the medication is only taken around the time of menstruation, which can last from 2 to 7 days.",
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"question": "Case Presentation: A 28-year-old presents to the GP complaining of severe pelvic pain around the time of menstruation. The pain is so severe it requires her to take time off work. This has been going on for several months and she takes regular paracetamol however the pain still persists. She is currently married and actively trying to conceive with her husband.\n\n\n## PH\n\nEczema\n\n## DH\n\nAllergies - penicillin\n\n## On examination\n\nNo cyanosis. Alert and orientated. Abdominal examination normal, with no palpable masses.\n\nTemperature 36.9°C, HR 76, RR 12, BP 120/88, O<sub>2</sub> saturation 97% RA, GCS 15, Weight 64kg\n\n## Investigations\n\nUrine beta-HCG -ve\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate for managing this patient's symptoms.\n\n",
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173,468,211 | false | 9 | null | 6,495,256 | null | false | [] | null | 6,775 | {
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"id": "33756",
"label": "d",
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"picture": null,
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"__typename": "QuestionComment",
"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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"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).",
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173,468,212 | false | 10 | null | 6,495,256 | null | false | [] | null | 6,783 | {
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"__typename": "QuestionComment",
"comment": "i mean the gabapentin is frequency not known on the bnf so this is just a shit question, better off putting just two options ",
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"comment": "The BNF often has 'frequency not known' even for potentially well known side effects. This usually when the drugs are quite old and didnt have the same testing requirements as today.",
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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 22-week pregnant woman who is 30 years old is admitted to the emergency department with suspected pre-eclampsia. PH Type 2 Diabetes mellitus, Epilepsy, Depression, Hashimoto’s Disease. DH Her current regular medications are listed (below).\n\n\n\n\n **On Examination**\nAbdominal tenderness, bilateral swelling of ankles.\n\n\n **Investigation**\nBP 145/95 mmHg. Na 120 mmol/L (135-145) Urine dipstick ++ protein\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be contributing to her hyponatremia (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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173,468,213 | false | 11 | null | 6,495,256 | null | false | [] | null | 6,789 | {
"__typename": "QuestionMultiA",
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33867",
"label": "f",
"name": "Salmeterol;50 micrograms;Inhaled (INH);12-hourly",
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"label": "a",
"name": "Amlodipine;5mg;Oral (PO);Daily",
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"explanation": null,
"id": "33863",
"label": "b",
"name": "Perindopril erbumine;8 mg;Oral (PO);Daily",
"picture": null,
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"explanation": null,
"id": "33864",
"label": "c",
"name": "Bendroflumethiazide;2.5 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
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"explanation": null,
"id": "33866",
"label": "e",
"name": "Simvastatin;40mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33869",
"label": "h",
"name": "Bisoprolol;5 mg;Oral (PO);OD",
"picture": null,
"votes": 0
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33865",
"label": "d",
"name": "Omeprazole;20mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "33868",
"label": "g",
"name": "Theophylline (Uniphyllin Continus®);200mg;Oral (PO);12-hourly",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Budesonide also causes hypokalaemia",
"createdAt": 1643564920,
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"comment": "Hypomagnesaemia (caused by omeprazole) can also precipitate hypokalaemia ",
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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": "2722",
"name": "Myopathy & drugs causing hypokalemia",
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"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"dislikes": 2,
"explanation": "1. Bendroflumethiazide is a thiazide-like diuretic. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. As a result of the reduced reabsorption, the concentration of Na+ left in the urine increases. The increase in Na+ availability increases the activity of Na+/K+-ATPase in the collecting duct and brings about an increase in excretion of K+ into the urine. Salmeterol is a long-acting β2 adrenergic receptor agonist (LABA). β2 adrenergic receptor agonist decreases the serum K+ level via an inward shift of K+ into the cells. Theophylline is a phosphodiesterase inhibitor. It is also known to cause hypokalaemia. BNF highlights that concomitant treatment of β2 adrenergic receptor agonist with theophylline may potentiate potentially serious hypokalaemia.\n2. Myalgia is a common or very common side effect of simvastatin.",
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"question": "Case presentation: A 49-year old man presents to the emergency walk-in clinic with muscle weakness and constipation. He also complains that he has been having pain in the muscles of his upper arms. PH: Hypertension, Asthma, GORD, Hypercholesterolaemia 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. Abdomen soft and non tender.\n\n\n **Vital signs**: BP 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18\n\n\n **Investigations**:\n\n\n - ECG: Prolonged QT, mild ST depression, presence of U wave\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|130 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|320x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|95 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|3 mmol/L|3.5 - 5.3|\n|Urea|7 mmol/L|2.5 - 7.8|\n|Creatinine|109 µmol/L|60 - 120|\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of his hypokalaemia (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that should be withheld in view of the patient’s myopathy? (mark it with a tick in column B)",
"sbaAnswer": null,
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} | MarksheetMark |
173,468,214 | false | 12 | null | 6,495,256 | null | false | [] | null | 6,799 | {
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"choices": [
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"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": "33940",
"label": "e",
"name": "Furosemide;40mg;Intravenous infusion (IV);Daily",
"picture": null,
"votes": 0
},
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33939",
"label": "d",
"name": "Ceftriaxone;2g;Intravenous infusion (IV);Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "33937",
"label": "b",
"name": "Metformin hydrochloride;500 mg;Oral (PO);Three times 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": "33936",
"label": "a",
"name": "Enalapril maleate;20 mg;Oral (PO);Daily",
"picture": null,
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},
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"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": "33943",
"label": "h",
"name": "Warfarin sodium;5 mg;Oral (PO);Daily",
"picture": null,
"votes": 0
},
{
"__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
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],
"comments": [
{
"__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)",
"sbaAnswer": null,
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"typeId": 3,
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173,468,215 | false | 13 | null | 6,495,256 | null | false | [] | null | 10,059 | {
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50040",
"label": "i",
"name": "Folic Acid;5mg;PO (Oral);Once Weekly",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50033",
"label": "b",
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"explanation": null,
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"label": "h",
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"explanation": null,
"id": "50038",
"label": "g",
"name": "Prednisolone;15mg;PO (Oral);Once Daily",
"picture": null,
"votes": 0
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"__typename": "QuestionChoice",
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"explanation": null,
"id": "50034",
"label": "c",
"name": "Amlodipine;5mg;PO (Oral);Once Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50037",
"label": "f",
"name": "Colecalciferol;400 units;PO (oral);Once Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50035",
"label": "d",
"name": "Carbamazepine;500mg;PO (Oral);Twice Daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50032",
"label": "a",
"name": "Methotrexate;10mg;PO (Oral);Once Weekly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50036",
"label": "e",
"name": "Alendronic Acid;700mcg;PO (Oral);Once Weekly",
"picture": null,
"votes": 0
}
],
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"__typename": "QuestionComment",
"comment": "The folic acid is also a serious error here, this should be prescribed daily (other than the day mtx is taken), not weekly.. ",
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"comment": "No its given once a week for patients taking methotrexate ",
"createdAt": 1675354213,
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"likes": 10,
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"displayName": "Hereditary Hematoma",
"id": 25272
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"comment": "Methotrexate has osteoporosis in the uncommon side effects list",
"createdAt": 1710104098,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "1. Long-term use of glucocorticoids such as prednisolone increase the risk of osteoporosis. Glucocorticoids should therefore only be used in short courses (up to 4 weeks) to treat flares of rheumatoid arthritis. Some antiepileptics (carbamazepine, phenytoin and sodium valproate) have been shown to increase the risk of osteoporosis when used long term.\n2. Alendronic Acid is used to treat osteoporosis, it should be prescribed in a weekly dose of 70mg or a daily dose of 10mg. 700mcg = 0.7mg. 700mcg would not be an effective dose to treat osteoporosis.",
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"question": "Case presentation: A 66-year-old female comes to the GP for a medication review. She reports that she currently has pain in her hands. \n\n\n**PH** Hypertension, Epilepsy, Rheumatoid Arthritis, Osteoporosis, Constipation\n\n**DH** Her regular medicines are listed (below).\n\n**On Examination** - Patient looks well, Hands: red erythematous swelling of metacarpophalangeal (MCPs) joints in the left hand, swelling of third proximal interphalangeal (PIPs) joint on the left hand. Pain on palpation of MCPs and PIPs. Reduced range of movement of left hands and wrists.\n\nTemperature 37.5°C, HR 88, RR 18, BP 134/94\n\n**Investigation** - Recent X-Ray of left-hand shows loss of joint space at MCPs and PIPs, Erosion at the third PIP and soft tissue swelling around the MCPs and third PIP.\n\nWeight 56kg.\n\nQuestion 1: Select the TWO prescriptions that increase the risk of osteoporosis (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)",
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173,468,216 | false | 14 | null | 6,495,256 | null | false | [] | null | 10,062 | {
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"id": "50065",
"label": "g",
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"id": "50066",
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"__typename": "QuestionChoice",
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"id": "50067",
"label": "i",
"name": "Metronidazole;500mg;IV;TDS",
"picture": null,
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"__typename": "QuestionChoice",
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"id": "50063",
"label": "e",
"name": "Salbutamol;200 micrograms;INH;QDS",
"picture": null,
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}
],
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{
"__typename": "QuestionComment",
"comment": "apparently atorvastatin and allopurinol shouldn't be co prescribed too according to the BNF?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "An increased risk of rhabdomyolysis when prescribing colchicine and atorvastatin together and a dosing error when prescribing lisinopril",
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"id": "13",
"name": "Neurosurgery",
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"explanation": "1. Colchicine should not be prescribed in patients with gout flare-ups who are taking statins. This is due to the reported increase in rhabdomyolysis when these medications are given together.\n\n2. Cefuroxime dosing is between 750mg to 1.5g IV TDS. This patient would be receiving 3g of cefuroxime over the maximum daily dose each day.",
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"id": "10062",
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"question": "Case presentation: A 68-year-old gentleman is admitted to the general surgical ward following an episode of diverticulitis. He is prescribed IV antibiotics to treat his diverticulitis.\n\n\n**PH** Diverticular disease, hypertension, hypercholesterolaemia, COPD, type 2 diabetes mellitus, gout\n\n**DH** His current medications are listed (below). Weight 88kg.\n\n**On Examination**\nHR 65/min, BP 135/95mmHg, RR 16, O2 sats 96% RA, temperature 37.7. Abdomen soft, tender in LIF region.\n\n**Investigation**\n\nCT abdomen and pelvis - uncomplicated sigmoid diverticulitis with no localised perforations.\n\nQuestion 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,468,217 | false | 15 | null | 6,495,256 | null | false | [] | null | 10,064 | {
"__typename": "QuestionMultiA",
"choices": [
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"__typename": "QuestionChoice",
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"id": "50084",
"label": "h",
"name": "Lansoprazole;30mg;PO;OD",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
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"id": "50078",
"label": "b",
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"id": "50081",
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"name": "Bisoprolol;5 micrograms;PO;OD",
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"__typename": "QuestionChoice",
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"id": "50082",
"label": "f",
"name": "Salbutamol;200 micrograms;INH;QDS",
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"id": "50083",
"label": "g",
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"id": "50080",
"label": "d",
"name": "Apixaban;5mg;PO;BD",
"picture": null,
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"answer": false,
"explanation": null,
"id": "50077",
"label": "a",
"name": "Ramipril;10mg;PO;OD",
"picture": null,
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}
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"__typename": "QuestionComment",
"comment": "surely the cause of the bleeding is the ibuprofen and therefore the cause of the anaemia, no?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "3596",
"name": "Apixaban can cause anaemia and a dosing error in bisoprolol",
"status": null,
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"id": "129",
"name": "Elderly medicine",
"typeId": 5
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"explanation": "1. Apixaban is a common cause of anaemia. As apixaban is a blood thinner, one of its common side effects is bleeding. This in turn then leads to anaemia. Ibuprofen and lansoprazole can also cause anaemia however this is much rarer.\n2. Bisoprolol dosages come in milligrams, not micrograms. This patient is receiving a much lower dose than they should be.",
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"question": "Case presentation: A 74-year-old gentleman attends his GP complaining of dizziness. \n\n\n\n\n **PH** Hypertension, atrial fibrillation, COPD, hypercholesterolaemia, osteoarthritis\n\n\n **DH** His regular medicines are listed (below). Weight 83kg.\n\n\n **Investigations**\n\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|111 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|4.8x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|236x10<sup>9</sup>/L|150 - 400|\n|Mean Cell Volume (MCV)|72 fL|80 - 96|\n|Neutrophils|2.2x10<sup>9</sup>/L|2.0 - 7.5|\n|Lymphocytes|1.3x10<sup>9</sup>/L|1.5 - 4.0|\n|Monocytes|0.4x10<sup>9</sup>/L|0.2 - 1.0|\n|Eosinophils|0.1x10<sup>9</sup>/L|0 - 0.4|\n|Basophils|0.03x10<sup>9</sup>/L|0 - 0.1|\n\n\nQuestion 1: Select the ONE prescription that is most likely to be a cause of his anaemia (mark them with a tick in column A)\n\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,468,218 | false | 16 | null | 6,495,256 | null | false | [] | null | 18,096 | {
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"id": "10028477",
"label": "b",
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"name": "Drugs causing diarrhoea (clindamycin, colchicine), dosing error (colchicine dose)",
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"explanation": "1. Diarrhoea is a well recognised side-effect of both clindamycin and colchicine, and patients should be informed of this before initiating the latter as it is often a reason for non-compliance. Given the patient is being given intravenous clindamycin they should also have a stool sample taken to rule out C.difficile infection.\n2. Colchicine is used to manage acute gout in patients with renal impairment in preference to allopurinol. It is important to recognise it is prescribed as *micrograms* not milligrams as in the prescription above.",
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"question": "Case presentation: A 73-year-old man is admitted to the acute medical ward with cellulitis. While an inpatient he also developed swelling and pain in his right knee and was commenced on medication for presumed gout. One day after starting this medication he started to experience non-bloody diarrhoea.\n\n\n**PH** Gout, Hypertension, Type 2 Diabetes, Gout, Chronic kidney disease, Osteoarthritis, Benign Prostatic Hyperplasia\n\n**DH** His current regular medicines are listed (below).\n\nAllergies - Penicillin (anaphylaxis)\n\n**On Examination**\nAfebrile, HR 84/min regular rhythm, BP 137/80 mmHg, mildly tender swollen right knee.\n\nQuestion 1: Select the TWO prescriptions that are most likely to be contributing to his diarrhoea. (mark them with a tick in column A)\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,468,219 | false | 17 | null | 6,495,256 | null | false | [] | null | 6,804 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Flucloxacillin is a narrow-spectrum penicillin antibiotic that is most commonly used to treat skin and soft tissue infections. It is not used in the treatment of streptococcal tonsillitis",
"id": "33969",
"label": "e",
"name": "Flucloxacillin 500mg PO QDS",
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"explanation": "While benzylpenicillin has activity against susceptible Gram-positive streptococci, an intravenous antibiotic would not be appropriate to treat likely uncomplicated streptococcal tonsillitis",
"id": "33968",
"label": "d",
"name": "Benzylpenicillin sodium 900mg IV TDS",
"picture": null,
"votes": 151
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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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"picture": null,
"votes": 10
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amoxicillin should not be given alone to treat suspected streptococcal tonsillitis due to the risk of misdiagnosed infectious mononucleosis and morbilliform drug eruption",
"id": "33967",
"label": "c",
"name": "Amoxicillin 500mg PO TDS",
"picture": null,
"votes": 144
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Phenoxymethylpenicillin is recommended first line to treat streptococcal tonsillitis in all age groups. Clarithromycin is an acceptable alternative option in penicillin-allergic patients",
"id": "33965",
"label": "a",
"name": "Phenoxymethylpenicillin 500mg PO QDS",
"picture": null,
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}
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "1st line treatment for streptococcal tonsillitis - penicillin V",
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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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173,468,220 | false | 18 | null | 6,495,256 | null | false | [] | null | 6,807 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dual antiplatelet therapy may be eventually indicated in the medical management of peripheral vascular disease but is no longer recommended as an initial treatment option. In addition, a high-dose statin should be prescribed",
"id": "33982",
"label": "c",
"name": "Aspirin 75mg PO OD and clopidogrel 75mg PO OD",
"picture": null,
"votes": 733
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"__typename": "QuestionChoice",
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"explanation": "This patient should be prescribed lipid-lowering therapy on account of likely peripheral vascular disease. However a statin should be the first line agent of choice rather than a fibrate, which are prescribed as adjuncts to statins or if statins are not appropriate",
"id": "33983",
"label": "d",
"name": "Clopidogrel 75mg PO OD and fenofibrate 200mg PO OD",
"picture": null,
"votes": 120
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "While antiplatelet therapy is recommended for the medical management of peripheral vascular disease, the current evidence supports the use of clopidogrel over aspirin. Aspirin may still be prescribed if clopidogrel is not tolerated",
"id": "33981",
"label": "b",
"name": "Aspirin 75mg PO OD and atorvastatin 80mg PO O",
"picture": null,
"votes": 1075
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "The initial medical management of peripheral vascular disease generally involves a single antiplatelet with preference for clopidogrel over aspirin as supported by the best available evidence. In addition, a high-dose statin should be prescribed",
"id": "33980",
"label": "a",
"name": "Clopidogrel 75mg PO OD and atorvastatin 80mg PO OD",
"picture": null,
"votes": 3167
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient is presenting with symptoms of intermittent claudication and risk factors suggesting he has peripheral vascular disease. As such he should be prescribed an antiplatelet drug such as clopidogrel and a high-dose statin. In this option the dosages are incorrect – the dose of clopidogrel is too high and the dose of atorvastatin is too low",
"id": "33984",
"label": "e",
"name": "Clopidogrel 300mg PO OD and atorvastatin 20mg PO OD",
"picture": null,
"votes": 366
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Where can you find this in the BNF?",
"createdAt": 1646844711,
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"id": "8299",
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{
"__typename": "QuestionComment",
"comment": "https://cks.nice.org.uk/topics/peripheral-arterial-disease/management/intermittent-claudication/#managing-cardiovascular-risk\nhttps://cks.nice.org.uk/topics/antiplatelet-treatment/\nhttps://bnf.nice.org.uk/drug/clopidogrel.html",
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"__typename": "QuestionComment",
"comment": "we cant use CKS in the exam...where can we find this info via medicine's complete?",
"createdAt": 1675167657,
"dislikes": 1,
"id": "17485",
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"__typename": "QuestionComment",
"comment": "BMJ Best practice states \"Antiplatelet therapy with aspirin is recommended.[2] Clopidogrel is an effective alternative to aspirin.\" Would the option with aspirin and the statin not also be correct?",
"createdAt": 1672407284,
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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 68-year-old man has been having pain in his legs for six months. The pain typically comes on when he is climbing stairs or has been walking for longer than 30 minutes, and is concentrated in the backs of his calves. **PH** hypertension. **DH** amlodipine 10mg PO OD. **SH** current smoker 10-20 per day, total 45 pack year history. NKDA\n\n\n**O/E**\n\nHR 74 regular, RR 14, BP 134/85. No pain at rest. Lower limbs pale and cool to knee level. Weak dorsalis pedis and posterior tibial pulses bilaterally. Normal power and tone, reflexes and sensation preserved. Capillary refill at toes 3s.\n\n**Investigations**\n\nABPI: 0.7 bilaterally\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,468,221 | false | 19 | null | 6,495,256 | null | false | [] | null | 6,810 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Doxycycline may be prescribed to treat recurrent aphthous stomatitis that may be idiopathic or secondary to herpesviruses. It has no role in the acute management of oral candidiasis",
"id": "33997",
"label": "c",
"name": "Doxycycline orodispersible tablets 100mg PO QDS",
"picture": null,
"votes": 10
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a medicated mouthwash with anti-inflammatory and analgesic properties. It has no role in the acute management of oral candidiasis",
"id": "33996",
"label": "b",
"name": "Benzydamine hydrochloride mouthwash 15ml PO TDS",
"picture": null,
"votes": 136
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Itraconazole may be an option for oral candidiasis that has not responded to first-line treatments",
"id": "33998",
"label": "d",
"name": "Itraconazole oral solution 100mg PO BD",
"picture": null,
"votes": 573
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Terbinafine is an antifungal drug commonly used to treat onychomycosis and ringworm. It has no role in the acute management of oral candidiasis",
"id": "33999",
"label": "e",
"name": "Terbinafine 250mg PO OD",
"picture": null,
"votes": 7
},
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"__typename": "QuestionChoice",
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"explanation": "Nystatin is a first-line antifungal treatment in the acute management of oral candidiasis. It is usually presecribed for 7 days",
"id": "33995",
"label": "a",
"name": "Nystatin 100,000 units PO QDS",
"picture": null,
"votes": 3780
}
],
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"__typename": "QuestionComment",
"comment": "Thought it was itraconzole... if you're unsure of what the first line med is, and there's no treatment summary, any other way you can find out using bnf? ",
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"comment": "if you go into Oropharyngeal fungal infections in medicine complete appears, and itraconazole will be used if fluconazole or 1st line treatment dont work",
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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": "Oral Thrush",
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"id": "74",
"name": "Elderly Care",
"typeId": 5
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"question": "Case Presentation: An 83 year old man is on the geriatric ward being treated for a grade III pressure sore. Today he is complaining of a foul taste in his mouth and some associated throat discomfort. **PH** hypertension, hyperlipidaemia, bilateral hemiarthroplasties. **DH** ramipril 2.5mg PO OD, amlodipine 10mg PO OD, simvastatin 40mg PO ON, paracetamol 1g PO QDS, senna 7.5mg PO BD, lactulose 15ml PO OD. NKDA\n\n\n**O/E**\n\nDry oral mucous membranes with halitosis. Visible white patches covering proximal 2/3rds of tongue that slough off when scraped with wooden depressor.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,468,222 | false | 20 | null | 6,495,256 | null | false | [] | null | 6,811 | {
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this",
"id": "34001",
"label": "b",
"name": "0.9% normal saline 200ml IV",
"picture": null,
"votes": 532
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phenoxymethylpenicillin may be given to treat streptococcal infections. There is no evidence such an infection is present in the stem",
"id": "34004",
"label": "e",
"name": "Phenoxymethylpenicillin 125mg PO",
"picture": null,
"votes": 143
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dexamethasone is an anti-inflammatory steroid medication commonly used to treat croup in the paediatric population. It has no role in the acute management of bronchiolitis",
"id": "34002",
"label": "c",
"name": "Dexamethasone 1.5mg PO",
"picture": null,
"votes": 869
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Bronchiolitis is generally managed conservatively unless there is evidence of disease severity (e.g cyanosis, <50% oral intake)",
"id": "34000",
"label": "a",
"name": "No additional treatment is required",
"picture": null,
"votes": 3232
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Palivizumab is a humanised monoclonal antibody that is used to prevent RSV infections in children at higher risk of severe disease. It is not routinely given without specialist paediatric input",
"id": "34003",
"label": "d",
"name": "Palivizumab 15mg IM",
"picture": null,
"votes": 61
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Not sure about his hydration level.",
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"comment": "''Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this'' - dude the stem says reduced oral intake\n\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 15 month old boy is brought to A&E by his parents with fever, cough and reduced oral intake.\n\n\n**O/E**\n\nTemperature 37.8°C. HR 104, RR 32 with persistent non-productive cough. O2 95% RA. Scattered fine crepitations and audible wheeze on auscultation. Appears pale pink and not cyanosed. Weight 10kg.\n\nHe has been given paracetamol oral suspension (Calpol Infant 120mg/5ml) 120mg PO and started on 4L oxygen wafted via simple face mask.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
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173,468,223 | false | 21 | null | 6,495,256 | null | false | [] | null | 6,812 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Paracetamol is available as a flavoured syrup for young children who will not tolerate tablets or are adverse to the bitter taste",
"id": "34005",
"label": "a",
"name": "Paracetamol oral suspension 240mg PO QDS",
"picture": null,
"votes": 2503
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amoxicillin may be given to treat acute otitis media that has not resolved after 3-4 days or if there is any evidence of complications",
"id": "34006",
"label": "b",
"name": "Amoxicillin 250mg PO TDS",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "Clarithromycin is an acceptable option in treating acute otitis media where antibiotics are required",
"id": "34008",
"label": "d",
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"picture": null,
"votes": 32
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is a combination medication given topically to treat acute otitis externa, or acute otitis media with grommets present",
"id": "34007",
"label": "c",
"name": "Ciprofloxacin with dexamethasone topical ear drops BD",
"picture": null,
"votes": 198
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While most cases of acute otitis media are self-limiting and resolve in a few days, the child is clearly in some pain and distress. At the very least, simple oral analgesia should be prescribed",
"id": "34009",
"label": "e",
"name": "No additional treatment is required",
"picture": null,
"votes": 1366
}
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"__typename": "Concept",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Uncomplicated otitis media",
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"question": "Case Presentation: A 4 year old girl is brought to GP by her parents as she has been unsettled and complaining of right-sided ear pain for the past 24 hours.\n\n\n**O/E**\n\nTemperature 37.0°C. HR 84, RR 15, O2 99% RA. Visibly restless and tugging at right pinna. Oropharynx pale pink with moist mucous membranes. Cervical lymph nodes not palpable. Otoscopy – left ear unremarkable, right ear hyperaemic tympanic membrane with loss of light reflex but no visible effusion.\n\nCardiovascular examination unremarkable. She has no known drug allergies.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
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173,468,224 | false | 22 | null | 6,495,256 | null | false | [] | null | 6,816 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"answer": true,
"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",
"picture": null,
"votes": 1486
},
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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
},
{
"__typename": "QuestionChoice",
"answer": false,
"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
},
{
"__typename": "QuestionChoice",
"answer": false,
"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": "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,
"dislikes": 0,
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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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"__typename": "QuestionComment",
"comment": "no amount of trying will ever get me to recall inducers/inhibitors. brazy",
"createdAt": 1706741289,
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"__typename": "QuestionComment",
"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.",
"sbaAnswer": [
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173,468,225 | false | 23 | null | 6,495,256 | null | false | [] | null | 10,117 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine. Fluoxetine is the first line medication for depression in children.",
"id": "50317",
"label": "d",
"name": "Fluoxetine 20mg PO OD",
"picture": null,
"votes": 94
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine as this is an antidepressant that is linked with increasing appetite the most.",
"id": "50314",
"label": "a",
"name": "Mirtazapine 15mg PO OD",
"picture": null,
"votes": 1910
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine.",
"id": "50318",
"label": "e",
"name": "Escitalopram 10mg PO OD",
"picture": null,
"votes": 21
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Sertraline would usually be the first line treatment however his issues with weight loss make mirtazapine a more appropriate choice.",
"id": "50315",
"label": "b",
"name": "Sertraline 50mg PO OD",
"picture": null,
"votes": 831
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine. Venlafaxine is often a second line medication in major depressive disorder.",
"id": "50316",
"label": "c",
"name": "Venlafaxine 25mg PO TDS",
"picture": null,
"votes": 22
}
],
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{
"__typename": "QuestionComment",
"comment": "In another mock test it said to try sertraline first before mirtazapine kms",
"createdAt": 1706626375,
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"comment": "this exactly",
"createdAt": 1706717918,
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"comment": "its because he's struggling with sleeping and eating, both of which mirtazapine help so its a better choice",
"createdAt": 1706979304,
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"comment": "where does it say on the BNF to use mirtazapine if appetite loss?",
"createdAt": 1737803019,
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"comment": "I think its just because of the additional side effects that it has\nMMMirtaZZZapine; increases MMM's appetite and ZZZ's sleepiness",
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"__typename": "QuestionComment",
"comment": "Thought mirtazapine was cautioned in elderly?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 78 year old man attends his GP due to low mood. He has issues with getting to sleep, concentration, general low mood and appetite. His main complaint is his appetite, he no longer eats as he used to and subsequently has lost weight. He has no suicidal ideation or impulse to hurt others.\n\n\n**PH** COPD, osteoarthritis\n\n**DH** Salbutamol 200 micrograms INH QDS, ibuprofen 400mg PO QDS, lansoprazole 30mg PO OD. NKDA\n\n**On examination**\n\nVisibly low mood. Lacking in engagement throughout the consultation.\n\nWeight 3 months ago: 76kg.\n\nWeight today: 68kg.\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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173,468,226 | false | 24 | null | 6,495,256 | null | false | [] | null | 10,120 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Doxycycline can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't.",
"id": "50330",
"label": "b",
"name": "Doxycycline 200mg PO OD for the first day then 100mg PO OD thereafter",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clarithromycin can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't.",
"id": "50331",
"label": "c",
"name": "Clarithromycin 500mg PO BD",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has cellulitis. He is systemically well therefore doesn't need to be admitted to hospital. He has no penicillin allergy therefore flucloxacillin is the appropriate management option for this patient.",
"id": "50329",
"label": "a",
"name": "Flucloxacillin 500mg PO QDS",
"picture": null,
"votes": 2752
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has an infection near the eyes or nose - which this patient doesn't have.",
"id": "50332",
"label": "d",
"name": "Co-amoxiclav 500/125mg PO TDS",
"picture": null,
"votes": 22
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Erythromycin can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't. If the patient is pregnant and has a penicillin allergy then this is the first line treatment option.",
"id": "50333",
"label": "e",
"name": "Erythromycin 500mg PO QDS",
"picture": null,
"votes": 15
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "BNF says 1-2g every 6 hours of flucloxacillin? ",
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"displayName": "Myotonia Sclerosis",
"id": 14530
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"name": "First line management of cellulitis",
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"name": "General Practice",
"typeId": 5
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"question": "Case Presentation: A 68 year old man attends his GP to a new rash. This rash is on his leg, is red and hot. \n\n\n**PH** Type 2 diabetes mellitus, hypertension\n\n**DH** Metformin 500mg PO BD, ramipril 5mg PO OD. NKDA\n\n**On examination**\nTemperature 37.6°C, HR 74, RR 15, BP 136/86, O2 98% RA.\n\nA 3x4cm rash is visualised on the anterior aspect of the right leg. It is hot and painful to touch.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 2830,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,468,227 | false | 25 | null | 6,495,256 | null | false | [] | null | 6,827 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin could cause hypoglycaemia, hence patients are encouraged to bring along a source of sugar with them at all times",
"id": "34084",
"label": "e",
"name": "Insulin is not known to cause hypoglycaemia",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin may lead to weight gain",
"id": "34083",
"label": "d",
"name": "Insulin may cause weight loss",
"picture": null,
"votes": 54
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin should be stored in the fridge and not the freezer because very low temperatures might damage the insulin",
"id": "34082",
"label": "c",
"name": "She should store the insulin in the freezer when not using",
"picture": null,
"votes": 75
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "During sickness, patients are advised to check blood glucose levels every 2 to 4 hours and adjust the insulin dose accordingly. It is common for patients to need an increased insulin dose during sickness to help keep the blood glucose level within control. There is a need for insulin dose to be increased because adrenaline and cortisol produced by the body to fight against infection may contribute to insulin resistance, ultimately leading to stress hyperglycaemia. Hence, patients are advised to never omit their insulin (especially basal long-acting insulin) even if there is a reduction in dietary intake",
"id": "34080",
"label": "a",
"name": "She should continue her long-acting insulin during sickness",
"picture": null,
"votes": 5112
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "When administering insulin, patients are advised to inject it at a different spot each time to prevent lipohypertrophy",
"id": "34081",
"label": "b",
"name": "She should inject insulin at the same spot each time",
"picture": null,
"votes": 10
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Insulin sick day rules",
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"question": "Case presentation: A 30-year-old woman visits her GP complaining of weight loss, excessive thirst and frequent urination. \r\n\nPMH: Coeliac disease, Vitiligo\nFH: Type 1 Diabetes Mellitus\nInvestigation: HbA1c 63 mmol/mol (20-42)\nTreatment with insulin is to be initiated.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,468,228 | false | 26 | null | 6,495,256 | null | false | [] | null | 6,838 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"label": "e",
"name": "If he forgets to take a dose of olanzapine, he should take a double dose to compensate for the forgotten dose",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Agranulocytosis is an uncommon but potentially fatal side effect of olanzapine",
"id": "34138",
"label": "d",
"name": "Agranulocytosis is a common side effect of olanzapine",
"picture": null,
"votes": 130
},
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"label": "b",
"name": "He will be registered with the patient monitoring service set up by the drug manufacturer",
"picture": null,
"votes": 127
},
{
"__typename": "QuestionChoice",
"answer": true,
"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",
"id": "34135",
"label": "a",
"name": "Olanzapine can increase appetite and lead to weight gain",
"picture": null,
"votes": 4231
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Olanzapine is linked to eosinophilia rather than low eosinophil counts",
"id": "34137",
"label": "c",
"name": "Olanzapine can cause low eosinophil count",
"picture": null,
"votes": 149
}
],
"comments": [
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"__typename": "QuestionComment",
"comment": "Why wouldn't you warn about fatal consequence of agranulocytosis?",
"createdAt": 1643888917,
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"comment": "Agranulocytosis is more relavent to Clozapine than Olanzapine ",
"createdAt": 1674535225,
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"displayName": "S ",
"id": 16952
}
}
],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"name": "Atypical antipsychotic",
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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.",
"sbaAnswer": [
"a"
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173,468,229 | false | 27 | null | 6,495,256 | null | false | [] | null | 6,839 | {
"__typename": "QuestionSBA",
"choices": [
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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,
"votes": 359
},
{
"__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,
"votes": 196
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients should refrain from dietary changes which reduce or increase sodium intake so that the lithium levels will not go deranged",
"id": "34144",
"label": "e",
"name": "He should go on a low salt diet to reduce the risk of lithium toxicity",
"picture": null,
"votes": 503
},
{
"__typename": "QuestionChoice",
"answer": false,
"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,
"votes": 135
},
{
"__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",
"picture": null,
"votes": 3477
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "Is a fine tremor nota normal side effect? With course tremors being a sign of toxicity? The type was not listed",
"createdAt": 1642435293,
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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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173,468,230 | false | 28 | null | 6,495,256 | null | false | [] | null | 6,848 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
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"explanation": "As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection",
"id": "34186",
"label": "b",
"name": "A white blood cell count should be performed before the treatment and then three monthly throughout the course of treatment",
"picture": null,
"votes": 70
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients who are women of childbearing age are encouraged to use effective contraception during treatment because carbimazole is linked to an increased risk of congenital malformations during pregnancy",
"id": "34187",
"label": "c",
"name": "It is safe for her to attempt to get pregnant during treatment",
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"__typename": "QuestionChoice",
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"explanation": "Carbimazole is a medication that is used to treat hyperthyroidism. A rare but serious side effect of carbimazole is bone marrow suppression leading to agranulocytosis. As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection. Hence, patients are advised to report immediately any signs and symptoms such as sore throat and infection",
"id": "34185",
"label": "a",
"name": "She should immediately report to her doctor if sore throat develops",
"picture": null,
"votes": 4294
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"explanation": "Haemolytic anaemia is a rare side effect of carbimazole",
"id": "34189",
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"name": "Haemolytic anaemia is a common side effect of carbimazole",
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"explanation": "The starting dose of carbimazole will be reduced gradually once the patients have become euthyroid. Patients will usually be started on a dose of 15-40 mg daily, taken divided into 2-3 doses a day. This may then be reduced after 4-8 weeks to a lower maintenance dose of 5-15 mg, taken once daily",
"id": "34188",
"label": "d",
"name": "She would be started on a low dose before the dose gets titrated upwards in a gradual manner in order to reduce risk of side effects",
"picture": null,
"votes": 50
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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 35-year-old woman attends her GP with a two-month history of weight loss, heat intolerance and sweating. \n\n\nPMH: Vitiligo\nInvestigations:\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|0.1 mU/L|0.3 - 4.2|\n|Free T4|30 pmol/L|9 - 25|\n\n - TSH receptor antibodies - Positive\n\n#\nThe patient is advised to commence treatment with carbimazole 15mg PO daily.\n\n\nQuestion: Select the most appropriate information that should be provided for this patient.",
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"explanation": "Gentamicin can cause drug induced nephrotoxicity. In patients with CKD however it is safe to use if it is used in the short term or at a reduced dosage. Gentamicin is thought to mainly contribute to a reduction in renal function in part due to apoptosis of proximal convoluted tubule cells.",
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"name": "Although this drug can cause acute kidney injury, it is safe to use in patients with chronic kidney disease",
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"explanation": "Hallucinations are a very rare side effect of enteral use of gentamicin.",
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"explanation": "Depression is a very rare side effect of gentamicin.",
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"name": "She is likely to experience changes to her mood when on gentamicin",
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"comment": "where could i find this info in the BNF ?",
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"comment": "gentamicin page in important safety information - 'To minimise the risks of adverse effects, continuous monitoring of renal and auditory function, as well as hepatic and laboratory parameters, is recommended for all patients.'",
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"comment": "A genuine question, i would appreciate some help. Would a doctor actually tell a patient \"Although this drug can cause acute kidney injury, it is safe to use in patients with chronic kidney disease\" ? ",
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"comment": "Given she has CKD it might be something she's worried about in which case yes but weird thing to pick as an exam Q ",
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"comment": "worth noting that dizziness is a common side effect of gent and patients often wont differentiate between those two",
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"comment": "how is that important advice, i dont think the patient would care",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case presentation: A 34-year-old woman attends the emergency department with abdominal pain, dysuria and rigors.\n\n\n**Observations**\n\n* Heart rate: 84 bpm\n* Respiratory rate: 14\n* Blood pressure: 111/84 mmHg\n* Temperature: 38.2 degrees celsius\n* Oxygen saturations: 97% on room air\n\n**PH**\nChronic kidney disease stage II\n\n**DH**\nNil\n\n**Investigations**\nUrine dip:\n\n* Nitrates ++\n* White blood cells ++\n* Red blood cells -\n\nUrine pregnancy test -ve\n\nIt is decided based on her presentation she has pyelonephritis, and she is due to be commenced on IV gentamicin. She is expected to be on antibiotics for a number of days. She has been reading about gentamicin online, and has some concerns given her past medical history.\n\nQuestion: Select the most important information that should be provided for this patient.",
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"explanation": "Hepatic monitoring is not routinely performed for patients taking prednisolone.",
"id": "50362",
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"name": "He will need regular hepatic function monitoring whilst taking prednisolone",
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"explanation": "Height and weight are monitored in paediatric patients taking prednisolone not adult patients. Weight may be monitored in adult patients as weight gain is a common side effect of steroid use.",
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"name": "His height and weight should be monitored whilst taking prednisolone",
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"explanation": "Vertigo is a uncommon side effect of corticosteroid use therefore it is not likely that this patient will experience this.",
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"name": "He is likely to experience vertigo when taking prednisolone",
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"explanation": "Prednisolone treatment for GCA occurs at high doses and can last a very long time, in some cases as long as two years. With prolonged use there is likely to be adrenal suppression, if there is abrupt withdrawal this can lead to acute adrenal insufficiency, hypotension and even death. A tapering regime in which the corticosteroid dose is slowly reduced over time is preferred due to this.",
"id": "50359",
"label": "a",
"name": "He should not abruptly stop taking his prednisolone",
"picture": null,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case presentation: A 68-year-old man attends the emergency with jaw pain. He mentions that he has found it difficult to chew and the side of his head is sore to touch.\n\n\n\n**PH** Hypertension, hypercholesterolaemia\n\n**DH** Ramipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD\n\n**Investigations** ESR 42 mm/hr (1-13 mm/hr)\n\nIt is decided that this gentleman likely has giant cell arteritis and he is promptly started on 40mg prednisolone PO OD.\n\nQuestion: Select the most important information that should be provided for this patient.",
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