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"explanation": "Intravaginal metronidazole can be used to treat bacterial vaginosis (BV). There is no indication of BV here as the woman does not complain of any unusual vaginal discharge. BV seldom results in vaginal bleeding.",
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"name": "Intravaginal metronidazole",
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"explanation": "Foetal fibronectin testing is used to detect foetal fibronectin in cervical secretions to rule out preterm labour. This woman has no signs of preterm labour. In addition, foetal fibronectin is usually only performed between weeks 22 and 35 weeks.",
"id": "49960",
"label": "d",
"name": "Perform foetal fibronectin testing",
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"explanation": "Since this woman has had a recent normal ultrasound scan, and displays no features of infection, the light bleeding is likely to be as a result of her slight cervical ectropion. This is a normal finding and is not a cause for concern.",
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"label": "a",
"name": "Reassurance and to return if symptoms worsen",
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"answer": false,
"explanation": "This woman would likely have had testing for chlamydia and gonorrhoea at her booking appointment. She has no other symptoms of infection and states she has a regular partner, so sexually transmitted infection is unlikely.",
"id": "49959",
"label": "c",
"name": "Obtain an endocervical swab for chlamydia testing",
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"answer": false,
"explanation": "Whilst this woman is overdue for her first cervical smear test, smear tests are generally not performed in pregnancy.",
"id": "49958",
"label": "b",
"name": "Perform a cervical smear test",
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"explanation": "# Summary\n\n\nAntepartum haemorrhage refers to vaginal bleeding occurring between the 24th week of pregnancy and birth. Key signs and symptoms may vary depending on the underlying cause but generally include vaginal bleeding, abdominal pain, and, in severe cases, signs of shock. Key investigations include taking a thorough clinical history, abdominal and speculum examination, blood tests, and ultrasound. Management involves assessing the patient's haemodynamic status, resuscitation if necessary, hospital admission for observation, and administration of antenatal corticosteroids if there's a risk of preterm birth.\n\n\n# Definition\n\n\n\nAntepartum haemorrhage is a clinical condition characterised by vaginal bleeding that occurs between the 24th week of pregnancy and birth.\n\n\n# Differential Diagnosis\n\n\n\nThe differential diagnosis for Antepartum haemorrhage includes:\n\n- Placental abruption: Symptoms may include vaginal bleeding, abdominal pain, and uterine tenderness or rigidity.\n- Placenta praevia: This condition may present with painless, bright red vaginal bleeding.\n- Vasa praevia: Signs may include vaginal bleeding and abnormal foetal heart rate patterns.\n- Genital tract malignancy or trauma: Symptoms may include vaginal bleeding, pelvic pain, and in cases of trauma, a history of injury.\n- Genital tract infection: Symptoms can include vaginal bleeding accompanied by fever, pelvic pain, and abnormal vaginal discharge.\n- Uterine rupture: This may present with sudden severe abdominal pain, vaginal bleeding, and signs of shock.\n- Inherited bleeding disorder: This condition can present with vaginal bleeding and a personal or family history of bleeding disorders.\n- Gestational trophoblastic disease: Symptoms may include vaginal bleeding, elevated hCG levels, and larger than expected uterine size.\n- Cervical ectropion: This condition may present with vaginal bleeding, especially post-coital.\n\n# Investigations\n\n\nIn the case of suspected antepartum haemorrhage, investigations should include:\n\n- Thorough clinical history\n- Abdominal examination\n- Speculum examination\n- Blood tests including group and save, crossmatch, full blood count, coagulation screen, urea and electrolytes, LFTs, and Kleihauer test in rhesus negative women.\n- Ultrasound to exclude placenta praevia \n- Cardiotocography to assess and monitor the foetus\n\n# Management\n\n\nManagement of antepartum haemorrhage involves:\n\n- Assessing haemodynamic status and initiating resuscitation if necessary\n- Admitting the patient to the hospital for observation\n- Obtaining intravenous access\n- Monitoring for concealed haemorrhage\n- Administering antenatal corticosteroids between 24 and 34 weeks of gestation if there is a risk of preterm birth.",
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"question": "A 26-year-old primiparous woman attends the maternity triage department with four episodes of vaginal bleeding. She is 21+5 weeks pregnant. She describes the bleeding as bright red and painless. Two episodes occurred immediately after intercourse with her regular partner, and two episodes have occurred unprovoked and have been noticed on wiping after using the toilet.\n\nShe has no vaginal discharge or other symptoms. She has no past medical history. She has never had a cervical smear test. She has attended both her booking appointment and her 20-week scan, and the pregnancy has been uncomplicated so far.\n\nOn examination, her observations are normal. A speculum examination reveals a normal cervix with a slight ectropion and no evidence of unusual vaginal discharge.\n\nWhat is the most appropriate next step?",
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"answer": true,
"explanation": "This describes a \"footlong\" breech presentation where the foetal foot is protruding from an undilated cervix. This is a contraindication to vaginal delivery.",
"id": "49962",
"label": "a",
"name": "Transfer to theatre for an emergency caesarean section",
"picture": null,
"votes": 1531
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vaginal delivery is contraindicated in footlong breech, so the woman should not be encouraged to push.",
"id": "49966",
"label": "e",
"name": "Advise the woman to push with each contraction to expedite delivery",
"picture": null,
"votes": 51
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vaginal delivery is contraindicated in a footlong breech presentation.",
"id": "49965",
"label": "d",
"name": "Reposition the cardiotocograph to obtain a reliable reading and proceed with vaginal delivery",
"picture": null,
"votes": 175
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is management for cord prolapse. In this case, inflating the maternal bladder is unlikely to affect foetal descent, since the foetal foot has already breached the cervix.",
"id": "49964",
"label": "c",
"name": "Inflate the maternal bladder with warm saline",
"picture": null,
"votes": 90
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Footlong breech presentation is a contraindication to vaginal delivery. Intravenous oxytocin would augment contractions in labour.",
"id": "49963",
"label": "b",
"name": "Administer intravenous oxytocin",
"picture": null,
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"explanation": "# Summary\n\nFetal presentation refers to the part of the fetus that presents first at the pelvic inlet during delivery. The three main categories include cephalic, breech, and shoulder presentations. Key signs and symptoms vary according to the type of presentation. The main investigation tool is an ultrasound scan, which can accurately determine the type of fetal presentation. Management strategies are based on the type of presentation and may include vaginal birth, cesarean section, or external cephalic version (ECV). \n\n\n# Definition\n\n\n\nFetal presentation is the orientation of the fetus in the womb that determines which part of the fetus presents first at the pelvic inlet during childbirth. \n\n\n# Epidemiology\n\n\n\nThe most common type of fetal presentation is the cephalic presentation, specifically the vertex presentation, which occurs in approximately 95% of term pregnancies. Breech and shoulder presentations are less common, with breech presentations occurring in about 3-4% of term pregnancies and shoulder presentations being a rare occurrence.\n\n\n# Aetiology\n\n\n\nThe cause of abnormal fetal presentations is often unclear but can be influenced by several factors such as prematurity, uterine abnormalities, placenta previa, multiple gestations, and previous cesarean sections.\n\n\n# Signs and Symptoms\n\n\n\nThe signs and symptoms vary according to the type of presentation:\n\n- Cephalic presentations: The most common sign is the baby's head being palpable at the base of the mother's abdomen.\n- Breech presentations: The baby's buttocks or feet may be palpable at the base of the mother's abdomen instead of the head.\n- Shoulder presentations: The baby's shoulder, arm, or trunk may be palpable at the base of the mother's abdomen.\n\n[lightgallery]\n\n[lightgallery1]\n\n[lightgallery2]\n\n# Investigations\n\n\nThe primary investigation for determining fetal presentation is an ultrasound scan. This imaging technique provides a clear view of the fetus's position in the womb and can identify the type of presentation accurately.\n\n# Management\n\n\nManagement strategies for abnormal fetal presentations include:\n\n- Vaginal birth: This is possible for some breech presentations, but it depends on the type of breech, the size of the baby, the size of the mother's pelvis, and the availability of a skilled practitioner.\n- Cesarean section: This is often recommended for breech and always for shoulder presentations due to the high risk of complications.\n- External cephalic version (ECV): This is a procedure where a healthcare provider manually turns the baby from a breech to a head-down position. It is usually attempted around 37 weeks of gestation. \n",
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"question": "A 34-year-old woman presents to accident and emergency with regular contractions at 38+5 weeks gestation.\n\nShe is transferred to the maternity department, where a midwife performs an examination. On examination, the abdomen is gravid, and the midwife cannot determine the foetal presentation. A cardiotocograph is difficult to obtain, but the foetal heart on auscultation is 145-160 beats per minute, with a variation of 10-15 beats per minute, and no decelerations. On vaginal examination, a foetal foot can be felt protruding from the cervix, which is approximately 6cm dilated. There is copious amounts of clear liquor draining from the vagina.\n\nWhat is the most appropriate management?",
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"answer": true,
"explanation": "Her weight of 97kg places her at a BMI of over 35. Any woman with a BMI >30 should be screened for gestational diabetes with a glucose tolerance test at 22-28 weeks.",
"id": "49967",
"label": "a",
"name": "Weight of 97kg",
"picture": null,
"votes": 914
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Previous macrosomia may prompt investigation for gestational diabetes, but not forceps delivery alone.",
"id": "49971",
"label": "e",
"name": "Previous forceps delivery",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A parent or sibling with diabetes would prompt investigation for gestational diabetes with a glucose tolerance test.",
"id": "49970",
"label": "d",
"name": "Maternal grandmother with type 2 diabetes and breast cancer",
"picture": null,
"votes": 106
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Previous baby >4.5kg would prompt screening for gestational diabetes with a glucose tolerance test at 22-28 weeks.",
"id": "49968",
"label": "b",
"name": "Previous baby >4kg",
"picture": null,
"votes": 917
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Women of South Asian, Black, Afro-Caribbean, and Middle-Eastern origin are at increased risk of gestational diabetes and are therefore offered screening at 22-28 weeks with a glucose tolerance test.",
"id": "49969",
"label": "c",
"name": "Irish origin",
"picture": null,
"votes": 112
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"__typename": "QuestionComment",
"comment": "I might just be dumb but im a bit confused on this question... isnt india in south asia? can someone explain why the answer is the BMI one?",
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"comment": "Both are correct it’s just quesmed having fun with us ",
"createdAt": 1684234714,
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"comment": "I'm confused, three of the answers seem to fall within the OGTT at 22-28 weeks criteria according to the explanations!",
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"comment": ">4 kg is a high risk factor",
"createdAt": 1717752386,
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"explanation": "# Summary\n\nGestational Diabetes Mellitus (GDM) is a condition of glucose intolerance that begins or is first detected during pregnancy, leading to insulin resistance. It affects approximately 5% of pregnancies and poses an increased risk of type 2 diabetes development. The condition is more prevalent among women from ethnic backgrounds with a high prevalence of type 2 diabetes, those with a previous history of GDM, and obese women. GDM may lead to complications such as macrosomia, shoulder dystocia, pre-term delivery, neonatal respiratory distress syndrome, and maternal hypertension, including perinatal complications. Management strategies typically involve a low glycemic index diet, regular physical activity, medication (metformin or insulin) based on specific glucose levels, and postpartum glucose testing to ensure resolution.\n\n\n# Definition \n\nGestational Diabetes Mellitus (GDM) is defined as glucose intolerance with fasting blood glucose levels equal to or above 5.6 mmol/L or 2-hour plasma glucose levels equal to or above 7.8 mmol/L on a 75g Oral Glucose Tolerance Test (OGTT).\n\n\n# Epidemiology\n\nApproximately 5% of pregnancies are affected by GDM. Women diagnosed with GDM have an increased risk of developing type 2 diabetes, with up to a 50% chance within 5-10 years postpartum.\n\n\n# Risk Factors\n\n\n\n- Ethnic backgrounds with a high prevalence of type 2 diabetes (e.g., Middle Eastern, South Asian, and Afro-Caribbean)\n- Prior history of GDM\n- Prior delivery of macrosomic babies (>4.5kg)\n- History of stillbirth or perinatal death\n- Maternal obesity (BMI>30)\n- Diabetes in first-degree relatives\n\n\n# Signs and Symptoms\n\n\n\nGDM often presents with no noticeable symptoms. However, some women may experience:\n\n- Polyuria\n- Thirst\n- Fatigue\n\n\n# Differential Diagnosis\n\n\n- Type 1 or Type 2 Diabetes Mellitus: Generally presents with symptoms outside of pregnancy, including potential weight loss\n- Other forms of gestational hyperglycaemia: These can be identified through early pregnancy HbA1c testing\n\n# Investigations\n\n\nDiagnosis of GDM is based on a 75g OGTT:\n\n- Fasting blood glucose level (fasting glucose ≥5.6 mmol/L)\n- 2-hour plasma glucose level (2-hour glucose ≥7.8 mmol/L)\n\nThis can be remembered as 'diagnosis of GDM is as easy as 5678'\n\nAdditional tests may include:\n\n- HbA1c: Helpful in distinguishing between gestational and pre-existing diabetes early in pregnancy\n- Urinalysis: To check for glycosuria\n\n# Foetal Complications\n\n- Macrosomia (birthweight >4kg): Excess maternal glucose crossing the placenta and inducing increased fetal insulin production can lead to macrosomia, increasing the risk of shoulder dystocia, birth injuries, and emergency caesarean section\n- Increased risk of sacral agenesis in the developing foetus\n- Pre-term delivery: May cause neonatal respiratory distress syndrome\n- Neonatal hypoglycaemia: High fetal insulin levels after delivery may lead to hypoglycaemia, which if severe, may result in seizures in the baby\n- Long-term risk: Increased risk of the baby developing type 2 diabetes later in life\n\n# Maternal Complications\n\n- Increased risk of hypertension and pre-eclampsia\n- Future risk: Increased risk of developing type 2 diabetes and GDM in subsequent pregnancies\n\n# Management\n\nManagement of GDM depends on specific glucose levels:\n\n- Lifestyle modifications, such as adopting a low glycemic index diet and regular physical activity, are the initial approach when fasting glucose levels are <7 mmol/L.\n\t- If blood glucose targets are not met with diet and exercise changes within 1 to 2 weeks, offer metformin.\n- If fasting glucose levels are ≥7 mmol/L, insulin therapy with or without metformin is often the first-line treatment.\n- Advise pregnant women with any form of diabetes to maintain their capillary plasma glucose below the following targets, if these are achievable without causing problematic hypoglycaemia:\n\t- Fasting: 5.3 mmol/litre\n\t- 1 hour after meals: 7.8 mmol/litre\n\t- 2 hours after meals: 6.4 mmol/litre\n- Postpartum management includes glucose testing to ensure resolution of GDM and long-term follow-up due to the increased risk of future type 2 diabetes.\n\n\n# NICE Guidelines\n\n[NICE CKS on Gestational Diabetes](https://www.nice.org.uk/guidance/ng3)\n\n",
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"question": "A 29-year-old parous woman attends for her 20-week scan. On examination, her blood pressure is 134/87. Her height is 165cm, and her weight is 97kg. She had a previous baby four years ago who was delivered via forceps delivery at 39+0 weeks gestation and weighed 4.2kg. She has no past medical history; however, her maternal grandmother has type 2 diabetes and breast cancer. Urinalysis is clear.\n\nWhich of the following features in her history would prompt glucose tolerance testing at 24 weeks?",
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"explanation": "Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement). This woman has signs and symptoms of pre-eclampsia but has not reported any seizures.",
"id": "49973",
"label": "b",
"name": "Eclampsia",
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"votes": 147
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"explanation": "Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement). This woman has signs and symptoms of pre-eclampsia but has not reported any seizures.",
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"label": "d",
"name": "Gestational hypertension",
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"votes": 50
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"explanation": "HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). This woman does not have any evidence of HELLP syndrome.",
"id": "49974",
"label": "c",
"name": "HELLP syndrome",
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"votes": 68
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"__typename": "QuestionChoice",
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"explanation": "Pre-eclampsia is defined as new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement. A frontal headache, peripheral oedema and hyperreflexia are other clinical signs.",
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"name": "Pre-eclampsia",
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"explanation": "Whilst labour may result in a slight increase in blood pressure and heart rate; this is not usually associated with proteinuria or other symptoms such as headache, peripheral oedema or brisk reflexes.",
"id": "49976",
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"explanation": "# Summary\n\nPre-eclampsia is a placental condition that often affects pregnant women from around 20 weeks of gestation, characterised by hypertension and proteinuria. Other symptoms include peripheral oedema, severe headache, drowsiness, visual disturbances, epigastric pain, nausea/vomiting and hyperreflexia. The exact aetiology is not entirely understood, but it may be due to dysfunctional trophoblast invasion of the spiral arterioles. Key investigations include blood pressure and urine protein measurements. Management strategies include anti-hypertensive treatment, with labetalol as the first-line agent. Magnesium sulphate is used to prevent and treat eclamptic seizures, but the ultimate curative treatment is delivery of the placenta.\n\n# Epidemiology\n\n\n\nPre-eclampsia affects a significant percentage of pregnancies worldwide, although the exact number varies significantly between different populations and healthcare settings. Risk factors include nulliparity, a previous history or family history of pre-eclampsia, increasing maternal age, pre-existing diseases such as hypertension, diabetes, renal disease, autoimmune disease, obesity, and multiple pregnancies.\n\n\n# Aetiology\n\n\n\nThe exact aetiology of pre-eclampsia remains unclear. However, it's believed to be related to dysfunctional trophoblast invasion of the spiral arterioles, which results in decreased uteroplacental blood flow and subsequent endothelial cell damage.\n\n\n# Signs and Symptoms\n\n\nPre-eclampsia is characterised by:\n\n- Hypertension\n- Proteinuria\n- Peripheral oedema\n- Severe headache\n- Drowsiness\n- Visual disturbances\n- Epigastric pain\n- Nausea/vomiting\n- Hyperreflexia\n\n# Maternal complications\n\n- Eclampsia (seizures due to cerebrovascular vasospasm)\n- Organ failure\n- Disseminated intravascular coagulation (DIC)\n- HELLP syndrome (the presence of haemolysis (H), elevated liver enzymes (EL) and low platelets (LP))\n\n# Foetal complications\n\n- Intrauterine growth restriction\n- Pre-term delivery\n- Placental abruption\n- Neonatal hypoxia\n\n\n# Differential Diagnosis\n\n\nThe differential diagnosis for pre-eclampsia includes other conditions that can present with hypertensive disorders in pregnancy, such as chronic hypertension, gestational hypertension, and HELLP syndrome. Key signs and symptoms for these conditions include persistent high blood pressure, proteinuria, and various combinations of haemolysis, elevated liver enzymes, and low platelet levels.\n\n# Investigations\n\n\nKey investigations for pre-eclampsia include:\n\n- Blood pressure measurement: To confirm hypertension.\n- Urinalysis: To confirm proteinuria.\n- Blood tests: To assess kidney function, liver function, and clotting status.\n\n# Management\n\nAspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with one high risk factor or two (or more) moderate risk factors. \n\nManagement of pre-eclampsia primarily involves anti-hypertensive treatment, with labetalol being the recommended first-line agent. Other agents that can be used include Nifedipine, Methyldopa and hydralazine. \n\nMagnesium sulphate can be administered for the prevention and treatment of eclamptic seizures. \n\nThe only definitive curative treatment is the delivery of the placenta. It is also crucial to monitor the mother and foetus closely for complications.\n",
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"question": "A 40-year-old primigravida at 38+2 weeks gestation presents with a headache unrelieved by analgesia. She has no significant past medical history. On examination, her abdomen is soft and non-tender, with slight ankle swelling and brisk reflexes.\n\n\n\nHer observations are as follows:\n\n\n\n - Heart rate: 92 beats per minute\n - Blood pressure: 168/101mmHg\n - Respiratory rate: 20 breaths per minute\n - SpO2: 99% on room air\n - Temperature 36.7°C\n\n\n\nCTG is reassuring.\n\n\n\nHer full blood count tests are as follows:\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|129 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|5.5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|385x10<sup>9</sup>/L|150 - 400|\n\n\n\n\n\n\nHer liver function tests are as follows:\n\n\n\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Albumin|35 g/L|35 - 50|\n|Alanine Aminotransferase (ALT)|40 IU/L|10 - 50|\n|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|\n|Alkaline Phosphatase (ALP)|103 IU/L|25 - 115|\n|Bilirubin|14 µmol/L|< 17|\n|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|\n|Lactate Dehydrogenase|168 IU/L|70 - 250 \n\n\n\nUrinalysis is positive for protein +++ and is otherwise negative.\n\n\n\nWhat is the most likely diagnosis?",
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"explanation": "Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician. This is usually the obstetric registrar, however may also be performed by a consultant.",
"id": "49979",
"label": "c",
"name": "Surgical repair by the obstetric consultant",
"picture": null,
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"explanation": "A one-off dose of broad-spectrum antibiotics is often given at the time of repair of perineal tears.",
"id": "49980",
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"name": "One week course of broad-spectrum antibiotics",
"picture": null,
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"explanation": "First-degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly. This tear is a second-degree tear, which does require repair.",
"id": "49981",
"label": "e",
"name": "Conservative management",
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"explanation": "Episiotomy is generally regarded as the same anatomical involvement as a second-degree tear, i.e. involving the perineal muscles and fascia but with the anal sphincter intact. Second-degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.",
"id": "49977",
"label": "a",
"name": "Suturing of the perineum by an experienced midwife",
"picture": null,
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"explanation": "Surgical repair is required in third and fourth-degree tears. This is usually performed by an experienced obstetric clinician.",
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"label": "b",
"name": "Surgical repair in theatre by the obstetric FY2",
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"explanation": "# Classification\n\nPerineal tears are the most common maternal obstetric injuries and can be classified into four categories:\n\n1. First degree tear\n - Tear limited to the superficial perineal skin or vaginal mucosa only\n2. Second degree tear\n - Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)\n3. Third degree tear\n - 3a: less than 50% of the thickness of the external anal sphincter is torn\n - 3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact\n - 3c: external and internal anal sphincters are torn, but anal mucosa is intact\n4. Fourth degree tear\n - Perineal skin, muscle, anal sphincter and anal mucosa are torn\n\n# Management\n\nManagement of a perineal tear depends on the degree of severity and classification of the tear, thus full assessment of the extent of the trauma is required before any intervention.\n\nFirst degree tears with minimal blood loss may not require suturing as they are superficial with no muscle involvement and are likely to heal quickly.\n\nSecond degree tears will require suturing as they involve perineal muscle. This may be carried out by an experienced midwife.\n\nThird and fourth degree tears require surgical repair by an experienced clinician and should take place in an operating theatre under regional or general anaesthetic.\n\nBroad-spectrum antibiotics and laxatives should be given post-operatively.\n\nAlthough some bleeding is expected with a tear, any excessive bleeding from the genital tract should prompt further investigation.",
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"question": "A 39-year-old multiparous woman has been in the second stage of labour for more than three hours, and has been actively pushing for over an hour. The foetal head can be seen at the peak of each contraction. A cardiotocograph shows decelerations with each contraction, which recover.\n\nA decision is made to perform an instrumental delivery. Local anaesthetic is infiltrated into the perineum and an episiotomy is performed. The forceps are applied and a live female infant is delivered after two contractions.\n\nThe midwife examines the woman's perineum following active management of the third stage of labour. The episiotomy is neat, and extends only to the perineal muscles and fascia, the anal sphincter is intact.\n\nWhat is the correct management?",
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"explanation": "Where first and second-line manoeuvres and internal rotation have not been successful, the woman should be prepared for theatre for e.g. symphysiotomy (dividing the anterior symphyseal ligament) or the Zavanelli manoeuvre (replacing the foetal head into the vagina in preparation for a caesarean section).",
"id": "49986",
"label": "e",
"name": "Prepare for theatre",
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"__typename": "QuestionChoice",
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"explanation": "Forceps are not used where the foetal head has already been delivered, as overzealous pulling can lead to foetal trauma.",
"id": "49985",
"label": "d",
"name": "Apply forceps to the foetal head to aid traction",
"picture": null,
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"explanation": "In cases of shoulder dystocia, the mother should be encouraged to stop pushing, as this can worsen shoulder impaction.",
"id": "49983",
"label": "b",
"name": "Ask the woman to hold her breath and bear down at least three times with each contraction",
"picture": null,
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"explanation": "Also known as McRobert's manoeuvre, the mother can be assisted to hyperflex and abduct her legs. This is the first-line manoeuvre in shoulder dystocia. It serves to increase the relative anterior-posterior diameter of the pelvis and is reported to be successful in up to 90% of cases of shoulder dystocia.",
"id": "49982",
"label": "a",
"name": "Hyperflexion and abduction of the mother's legs",
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"explanation": "Fundal pressure should not be applied during a shoulder dystocia, as this can precipitate uterine rupture. McRobert's manoeuvre may be augmented by moderate suprapubic pressure.",
"id": "49984",
"label": "c",
"name": "Apply fundal pressure",
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"explanation": "# Summary\n\nShoulder dystocia is a specific form of obstructed labour where the foetal anterior shoulder becomes lodged behind the maternal pubic symphysis post-delivery of the foetal head. Key signs include difficulty in delivering the foetal face or chin, retraction of the foetal head, failure of restitution, and descent of the shoulders following head delivery. Management involves immediate help calling, avoiding fundal pressure and maternal pushing, employing various manoeuvres, and monitoring both mother and baby post-delivery for injuries and complications.\n\n# Definition\n\nShoulder dystocia is a specific type of obstructed labour, where following the delivery of the foetal head the anterior shoulder becomes impacted behind the maternal pubic symphysis.\n\n# Risk factors\n\n- Maternal gestational diabetes\n- Macrosomia\n- Birthweight >4kg\n- Advanced maternal age\n- Maternal short stature or small pelvis\n- Maternal obesity\n- Post-dates pregnancy\n\n# Clinical features\n\nPrompt recognition of shoulder dystocia is important for timely management and thus routine observation should be made for:\n\n- Difficult delivery of the foetal face or chin\n- Retraction of the foetal head (turtle-neck sign)\n- Failure of restitution\n- Failure of descent of the foetal shoulders following delivery of the head\n\n# Management\n\nOnce shoulder dystocia has been recognised, management is as follows:\n\n- Immediately call for help - further midwifery assistance, senior obstetrician, paediatrician and anaesthetist may be required\n- Do not apply fundal pressure as this may lead to uterine rupture and discourage maternal pushing as this may exacerbate shoulder impaction\n\n1. McRoberts manoeuvre\n\n- Hyperflexion and abduction of the mother's legs tightly to the abdomen\n- This may be accompanied with applied suprapubic pressure\n- Routine traction (as applied during normal delivery) in an axial direction should be applied to assess whether the shoulders have been released.\n\n2. All fours position\n\n3. Internal rotational manoeuvres:\n\n - Woods' screw manoeuvre: anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.\n - Rubin manoeuvre II: rotation of the anterior shoulder towards the foetal chest\n - Note that episiotomy will not relieve shoulder dystocia as it is a bony obstruction, but may be indicated to allow space for internal rotational manoeuvres.\n\n4. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)\n\n5. Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section\n\nFollowing the delivery of a baby after shoulder dystocia:\n\n- The mother should be examined and monitored for postpartum haemorrhage, severe perineal tears and other genital tract trauma.\n- The baby should be examined by a neonatologist for injury including brachial plexus injury, hypoxic brain damage, humeral or clavicular fractures",
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"question": "A 22-year-old woman is in the second stage of labour and has just delivered the foetal head. The midwife notes that restitution does not occur. She is unable to deliver the anterior shoulder and pulls the emergency buzzer.\n\nWhat is the most appropriate action?",
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"explanation": "Placenta increta occurs where the placental villi invade into, but not through, the myometrium.",
"id": "49988",
"label": "b",
"name": "Placenta increta",
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"votes": 454
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"__typename": "QuestionChoice",
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"explanation": "Placenta praevia occurs where the placenta overlies the cervical os. This can result in antepartum haemorrhage, and is usually diagnosed antenatally.",
"id": "49990",
"label": "d",
"name": "Placenta praevia",
"picture": null,
"votes": 43
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"__typename": "QuestionChoice",
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"explanation": "Vasa praevia occurs where the foetal vessels run near to or across the internal cervical os, unsupported by the umbilical cord or placental tissue. This can cause antepartum haemorrhage due to rupture of the foetal vessels during rupture of membranes.",
"id": "49991",
"label": "e",
"name": "Vasa praevia",
"picture": null,
"votes": 25
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"explanation": "Placenta percreta occurs where the placental villi invade through the full thickness of the myometrium to the serosa.",
"id": "49989",
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"name": "Placenta percreta",
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"explanation": "Placenta accreta occurs where the placental villi adhere directly to the superficial myometrium. In placenta accreta, the placental villi do not penetrate into the myometrium itself. Placenta accreta is the most common placental implantation abnormality, and is typically diagnosed antenatally.",
"id": "49987",
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"name": "Placenta accreta",
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"explanation": "# Summary\n\nPlacental accreta refers to a spectrum of abnormalities involving the implantation of the placenta into the uterine wall. It is associated with various risk factors such as previous pregnancy termination, dilation and curettage, caesarean section, advanced maternal age, placenta praevia, and uterine structural defects. Diagnosis may be difficult to establish antenatally, with Doppler ultrasound and MRI scanning providing valuable information. Placental accreta can lead to complications like severe postpartum bleeding, preterm delivery, and uterine rupture. Management strategies often involve an elective caesarean section and hysterectomy, but in cases where fertility preservation is necessary, a less destructive placental resection may be performed.\n\n\n# Definition\n\nPlacental accreta is a spectrum of abnormalities of placental implantation into the uterine wall.\n\n# Risk factors\n\nRisk factors for placental accreta spectrum include:\n\n- Previous termination of pregnancy\n- Dilatation and curettage\n- Previous caesarean section\n- Advanced maternal age\n- Placenta praevia\n- Uterine structural defects\n\n# Classification\n\n**Placenta accreta** occurs where adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle.\n\n**Placenta increta** occurs where the villi invade _into_ but not _through_ the myometrium\n\n**Placenta percreta** occurs when the villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.\n\n# Diagnosis\n\nDoppler ultrasound and MRI scanning are useful investigations, but antenatal diagnosis can be difficult to make.\n\n# Complications\n\nAbnormal implantation of the placenta can lead to increased risk of severe postpartum bleeding, preterm delivery and uterine rupture.\n\n# Management\n\nIf abnormal placental implantation is suspected, the safest management plan is often an elective caesarean section and hysterectomy.\n\nIf it is important to preserve the patient's fertility, a less destructive placental resection may be attempted.",
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"question": "A 39-year-old woman is scheduled for an elective caesarean section due to a previous caesarean section at 38+4 weeks gestation.\n\nA lower uterine segment caesarean section is performed and a live male infant is delivered. Following delivery of the infant, there is brisk bleeding from the placental site, and the placenta is found to be adherent to the uterine wall.\n\nBleeding is unable to be controlled and the lower uterine segment is closed and a total hysterectomy is performed.\n\nPathology reports an abnormally adherent placental with the placental villi adhering directly onto the superficial myometrium.\n\nWhat is the most likely reason for this patient's postpartum haemorrhage?",
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"__typename": "QuestionChoice",
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"explanation": "Peginterferon alfa and ribavirin are used in the management of chronic hepatitis C infection.",
"id": "49995",
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"explanation": "Zidovudine monotherapy is used for post-exposure prophylaxis in an infant born to a low-risk mother (i.e. low viral load, <50 HIV RNA copies/mL). Zidovudine is also used for the management of untreated women presenting in labour at term, and is given intravenously throughout labour.",
"id": "49993",
"label": "b",
"name": "Start daily zidovudine immediately",
"picture": null,
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"id": "49992",
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"explanation": "All pregnant women should be commenced on ART immediately. Tenofovir disoproxil monotherapy is sometimes used to treat pregnant women with hepatitis B infection.",
"id": "49994",
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"name": "Plan to start tenofovir disoproxil daily in the third trimester",
"picture": null,
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"explanation": "Benzathine penicillin is the recommended treatment option for syphilis infection",
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"picture": null,
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"comment": "Starting ARTs, yes. The specific regimen? Highly specialised ",
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"explanation": "# Overview\n\nPatients with HIV should be supported in making an informed decision regarding the risks associated with their pregnancy and delivery.\n\nWithout intervention, the likelihood of passing HIV from mother to child is around 25-40%, 90% of which occurs during delivery. Infection is rarely passed in utero.\n\n# Management\n\n- It is imperative to start the mother on combination antiretroviral therapy (cART) as soon as a diagnosis is confirmed.\n- If the mother's viral load is <50, a normal vaginal delivery can be recommended and supported. If the viral load is greater than 50, an elective caesarean section is recommended\n- The baby will be recommended infant post exposure prophylaxis (PEP) with either zidovudine monotherapy or cART. The duration and choice of therapy depends on the risk of transmission (e.g. maternal viral load, resistance patterns)\n- In the UK, the safest way to feed infants born to women with HIV is with formula milk, as there is no on-going risk of HIV exposure after birth\n- However women with a low viral load on cART who choose to breastfeed should be informed of the risk of transmission, but supported to breastfeed if they wish, alongside additional monitoring.\n\n# References\n\n[Click here for the British HIV Association Guidelines on the management of HIv in pregnancy](https://www.bhiva.org/file/5f1aab1ab9aba/BHIVA-Pregnancy-guidelines-2020-3rd-interim-update.pdf)",
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"question": "A 37-year-old nulliparous woman attends for her first antenatal appointment at approximately eight weeks gestation. She is routinely screened for HIV, syphilis and hepatitis B.\n\nHer HIV test is reported as positive, and a confirmatory test is carried out.\n\nWhat is the most appropriate management?",
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173,458,741 | false | 41 | null | 6,494,970 | null | false | [] | null | 10,036 | {
"__typename": "QuestionSBA",
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"explanation": "Ectopic pregnancy is unlikely to occur in the context of fertility treatments, as woman are usually advised to abstain from intercourse during ovarian stimulation. Ectopic pregnancy often presents with unilateral pain, associated with haemodynamic instability. It would be unusual to present with peripheral oedema and pleural effusion.",
"id": "50000",
"label": "d",
"name": "Ectopic pregnancy",
"picture": null,
"votes": 9
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"__typename": "QuestionChoice",
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"explanation": "Whilst ovarian torsion is a likely diagnosis, associated with ovarian stimulation, it typically presents with unilateral pain which is sudden in onset and not usually associated with peripheral oedema or pleural effusion.",
"id": "50001",
"label": "e",
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"votes": 21
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"explanation": "Whilst oocyte retrieval carries a risk of pelvic infection, this woman is apyrexial and does not complain of any pelvic pain or unusual vaginal discharge.",
"id": "49998",
"label": "b",
"name": "Pelvic infection",
"picture": null,
"votes": 46
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"explanation": "Whilst intraabdominal haemorrhage may present with abdominal discomfort and tachycardia, this would be an unusual complication of oocyte retrieval. In addition, this is unlikely to cause peripheral oedema or pleural effusion.",
"id": "49999",
"label": "c",
"name": "Intraabdominal haemorrhage",
"picture": null,
"votes": 109
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"explanation": "Ovarian hyperstimulation syndrome (OHSS) is a clinical diagnosis based on a typical history and examination findings. OHSS typically occurs following treatment with follicle-stimulating hormone (FSH), which promotes follicular maturation during fertility treatments. OHSS is associated with an excessive ovarian response, leading to fluid shift into the extravascular spaces, hence causing peripheral oedema, ascites and pleural effusion. The management is typically supportive.",
"id": "49997",
"label": "a",
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"explanation": "# Summary\n\n\nOvarian hyperstimulation syndrome (OHSS) is a potentially severe complication of iatrogenic induction of ovulation, often associated with in-vitro fertilization (IVF) procedures. It is characterized by an exaggerated response to hormonal therapies leading to the excessive production of oestrogen, progesterone, and local cytokines. Key signs and symptoms include bloating, abdominal discomfort, and fluid retention, which can manifest as oedema, pleural effusions, ascites, and weight gain. Investigations often involve routine blood tests to assess haemoconcentration and organ dysfunction, and a chest X-ray to detect pleural effusion. Management is primarily supportive, ranging from simple analgesia to intensive care unit (ICU) admission, depending on the severity of the condition.\n\n\n# Definition\n\n\nOvarian hyperstimulation syndrome (OHSS) is a complication arising from iatrogenic induction of ovulation, characterized by an exaggerated response to hormonal therapies used in procedures such as in-vitro fertilization (IVF).\n\n\n\n# Aetiology\n\n\nOHSS occurs due to an excessive response to hormones used in IVF, leading to multiple follicles maturing and enlarging. Upon ovulation, each of these follicles transforms into a corpus luteum, resulting in an overproduction of oestrogen, progesterone, and local cytokines, especially vascular endothelial growth factor (VEGF).\n\n\n# Signs and Symptoms\n\n\nThe overstimulation of the ovaries can cause significant enlargement, leading to pressure on surrounding structures. This can result in the following symptoms:\n\n- Bloating\n- Abdominal discomfort\n\nVEGF can cause blood vessels to leak, leading to fluid retention manifesting as:\n\n- Oedema\n- Pleural effusions\n- Ascites\n- Weight gain\n\n# Investigations\n\nThe following investigations are often conducted to diagnose OHSS and assess the severity:\n\n- Routine blood tests: These are used to evaluate haemoconcentration and detect potential organ dysfunction.\n- Chest X-ray: This is performed to identify the presence of pleural effusion.\n\n# Management\n\nThe management of OHSS is largely supportive and tailored according to the severity of the condition. It can range from administration of simple analgesia to manage discomfort, to admission to the intensive care unit (ICU) for more severe cases. Ongoing monitoring and supportive care are essential to prevent complications and promote recovery.",
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"question": "A 45-year-old woman attends accident and emergency feeling generally unwell. She is undergoing fertility treatment and has just undergone oocyte retrieval the day prior, which yielded 14 oocytes.\n\nOn examination, her observations are as follows:\n\n- Temperature: 37.6°C\n- Respiratory rate: 25 breaths per minute\n- Heart rate: 110 beats per minute\n- Blood pressure: 115/62mmHg\n- Oxygen saturations: 97%\n\nHer abdomen is distended, tense and uncomfortable. She has peripheral oedema evident in her feet. Her lungs are clear; however the bases of both lungs are dull to percussion.\n\nWhat is the most likely diagnosis?",
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"a"
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173,458,742 | false | 42 | null | 6,494,970 | null | false | [] | null | 10,037 | {
"__typename": "QuestionSBA",
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"explanation": "Long-acting benzodiazepines such as clobazam may be considered in high-risk epileptics such as those who have had recent seizures, have a history of seizure provocation by stress or sleep deprivation, or have suffered seizures in a previous labour.",
"id": "50005",
"label": "d",
"name": "Oral clobazam 20mg daily",
"picture": null,
"votes": 24
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intravenous lorazepam is used to treat seizures, and would not be an appropriate routine part of labour management.",
"id": "50003",
"label": "b",
"name": "Intravenous lorazepam at a dose of 0.1 mg/kg",
"picture": null,
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"answer": false,
"explanation": "Intramuscular vitamin K should be administered to all babies born to women with epilepsy to prevent haemorrhagic disease of the newborn. It should not be adminstered to the mother.",
"id": "50006",
"label": "e",
"name": "Intramuscular vitamin K, 1 mg",
"picture": null,
"votes": 373
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Women should continue taking their regular anti-epileptic drugs orally during labour where tolerated.",
"id": "50002",
"label": "a",
"name": "Oral Levetiracetam 500mg twice daily",
"picture": null,
"votes": 774
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Intravenous therapy may be used where oral therapy is not tolerated in labour. There is no indication in this stem that the patient is unable to take her regular medication.",
"id": "50004",
"label": "c",
"name": "Intravenous Levetiracetam 500mg twice daily",
"picture": null,
"votes": 448
}
],
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"__typename": "QuestionComment",
"comment": "what a random question",
"createdAt": 1683906579,
"dislikes": 1,
"id": "24236",
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"comment": "Ok I checked RCOG guidelines for intrapartum care\nIf LOW RISK of seizures, continue regular medications, switching to IV instead of oral only if the oral route becomes intolerable or insufficient (Vomiting for example)\nIf high risk of seizures, or not well controlled, give Clobazam intrapartum\nThe baby, NOT THE MOTHER, gets Vit K postpartum",
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"comment": "How do you know what is considered high risk and low risk ",
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"comment": "I think as seizure free throughout pregnancy",
"createdAt": 1715460123,
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"explanation": "# Management of epilepsy in pregnancy (pre-pregnancy)\n\n\n\n- Neurology review should be sought to assess existing anti-epileptic medication and aim for monotherapy (single drug regime). The lowest effective dose of the medication should be used.\n- Levetiracetam and lamotrigine are the safest anti-epileptic medications to use during pregnancy. Sodium valproate should be avoided in pregnancy as it carries the highest risk of congenital defects.\n- In general women with history of epilepsy but with no high risk of unprovoked seizures can be managed as low risk pregnancies and if no fits have occurred for at least 2 years consider stopping all medication.\n- Drug compliance must be emphasised and the woman should be advised to continue her medication through pregnancy.\n- All need to take 5mg/day of folic acid pre-conceptually until at least the end of the first trimester. This is to minimise the risk of neural tube defects and folate deficiency.\n\n# Management of epilepsy in pregnancy (Antenatal)\n\n- All pregnant women with epilepsy should be under joint medical and obstetric care.\n- Plasma anti-epileptic drugs levels should be monitored regularly, as levels are likely to decrease with increasing plasma volume during pregnancy.\n- The foetus should be monitored throughout pregnancy for abnormalities with serial growth and anomaly scans.\n- Anti-epileptic regimes may inhibit foetal clotting factor production so vitamin K therapy should be given from 36 weeks gestation.\n- Pregnant women with epilepsy should be reassured that most will have an uncomplicated labour and delivery and that there are no specific differences in labour management compared to non-epileptic women.\n- If epileptic seizures do occur during labour, they should be terminated as quickly as possible with benzodiazepines in order to avoid maternal and foetal hypoxia.\n- Note that if a pregnant women with no previous diagnosis of epilepsy presents after the first trimester with seizures, the immediate management guidelines for eclampsia should be followed until a definitive neurological diagnosis can be made.\n\n# Management of epilepsy in pregnancy (Postnatal management)\n\n- It is generally safe to take anti-epileptic drugs whilst breastfeeding.\n- The anti-epileptic doses should be reviewed after delivery to prevent postpartum toxicity as plasma levels return to normal.",
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"question": "A 22-year-old woman attends the maternity unit in established labour. She has a past medical history of epilepsy, and has been seizure-free throughout pregnancy on a stable dose of 500mg levetiracetam twice daily.\n\nWhich of the following is likely to be administered to her as part of her labour management?",
"sbaAnswer": [
"a"
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173,458,743 | false | 43 | null | 6,494,970 | null | false | [] | null | 10,038 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst post-coital bleeding may be a sign of cervical cancer, in the absence of any other signs or symptoms, and where the cervix appears normal, it is prudent to rule out other causes of post-coital bleeding such as sexually transmitted infection",
"id": "50010",
"label": "d",
"name": "Refer to gynaecology under the two week wait",
"picture": null,
"votes": 926
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Regardless of the fact this woman is in a regular relationship, one of the most common causes of post-coital bleeding is sexually transmitted infection, so this is important to rule out.",
"id": "50007",
"label": "a",
"name": "Test for sexually transmitted infections",
"picture": null,
"votes": 611
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cervical smears are a screening test and, as such, are indicated in accordance with screening protocol - this is every 3-5 years in the UK, depending on age and location. Opportunistic smear tests are not indicated or encouraged.",
"id": "50008",
"label": "b",
"name": "Routine cervical smear",
"picture": null,
"votes": 226
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Progestogen-only contraception is associated with irregular bleeding and spotting, however is not usually associated with post-coital bleeding. Replacement of the implant early is not indicated in this case.",
"id": "50011",
"label": "e",
"name": "Replace her contraceptive implant",
"picture": null,
"votes": 41
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this woman may merit referral to colposcopy, routine tests such as testing for sexually transmitted infections should be performed in primary care first.",
"id": "50009",
"label": "c",
"name": "Refer to colposcopy",
"picture": null,
"votes": 271
}
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"__typename": "QuestionComment",
"comment": "Good luck trying to get into sexual health screening these days...\n",
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"__typename": "QuestionComment",
"comment": "Surely you would refer as STI screening takes time\n",
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"explanation": "# Summary\n \n \nPost-coital bleeding, a condition defined by vaginal bleeding after sexual intercourse, is a symptom that is almost always abnormal and requires medical attention. It can be indicative of various conditions such as cervical ectropion, endocervical and cervical polyps, cervical cancer, sexually transmitted infections, and atrophic vaginitis. Key investigations to diagnose these conditions often include speculum examination, screening for STIs and in some cases, biopsy. Management strategies are typically dependent on the underlying cause and range from conservative observation to medical therapies and surgical interventions.\n \n \n# Definition\n \n \nPost-coital bleeding refers to any vaginal bleeding occurring after sexual intercourse. This is a symptom that is not typically expected and is almost always indicative of an underlying abnormality, except in the case of first-time intercourse.\n \n\n# Epidemiology\n \n \nThe prevalence of post-coital bleeding varies widely due to differences in study designs and populations. It is estimated that about 0.7% to 9% of menstruating women experience post-coital bleeding. The prevalence increases with age, particularly in post-menopausal women where atrophic vaginitis becomes more common.\n \n \n# Aetiology\n \n \nPost-coital bleeding is a symptom, not a disease. It can result from a number of conditions including:\n \n \n - Cervical ectropion\n - Endocervical and cervical polyps\n - Cervical cancer\n - Sexually transmitted infections\n - Atrophic vaginitis\n \n \n# Signs and Symptoms\n \n \nPost-coital bleeding is often accompanied by other symptoms, depending on the underlying cause. \n \n \n - **Cervical ectropion:** Often asymptomatic. May present with post-coital bleeding or vaginal discharge.\n - **Endocervical and cervical polyps:** Often asymptomatic. May present with abnormal vaginal bleeding (post-coital, inter-menstrual, or menorrhagia).\n - **Cervical cancer:** May cause post-coital bleeding, spontaneous bleeding, or bleeding after urination. Other symptoms include urinary changes and vaginal discomfort.\n - **Sexually transmitted infections:** Common symptoms include discharge and pelvic pain, in addition to post-coital bleeding.\n - **Atrophic vaginitis:** The vaginal mucosa becomes drier and thinner, which can lead to bleeding, particularly after intercourse.\n \n \n# Investigations\n \n \nInvestigations for post-coital bleeding include:\n \n **Bedside:**\n \n - Speculum examination\n - Cervical swab and cytology\n - Endocervical and high vaginal swabs \n\n**Bloods:**\n \n - FBC and CRP\n\nNone of the above conditions require **imaging** for diagnosis. Cervical cancer would require CT for staging. \n\n**Invasive:**\n\n - Colposcopy or biopsy if required (e.g. if suspicious lesion on speculum and/or if screening is overdue). \n \n \n# Management\n \n \nThe management of post-coital bleeding depends on the underlying cause. You can find short descriptions below, but please consult the page for each of the conditions for full management. \n \n \n - Cervical ectropion (asymptomatic): conservative management. \n - Endocervical and cervical polyps (symptomatic): polypectomy.\n - Cervical cancer: based on staging, and may include surgery, radiation therapy, or chemotherapy.\n - Sexually transmitted infections: antibiotics.\n - Atrophic vaginitis: topical oestrogen therapy. \n\n \n# References\n\n[Owens et al. Investigation and Management of Postcoital Bleeding. 2022. *Wiley*.](https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/tog.12780)\n\n[Patient Info](https://patient.info/doctor/intermenstrual-and-postcoital-bleeding)\n\n[GP Notebook](https://primarycarenotebook.com/pages/gynaecology/postcoital-bleeding)\n\n[North Tees and Hartlepool NHS Foundation Trust - Post-coital bleeding](https://www.nth.nhs.uk/resources/post-coital-bleeding/)",
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"question": "A 43-year-old woman attends her general practitioner with three episodes of bleeding after sex.\n\nShe has a regular male partner and has a progestogen-only implant for contraception which has been in situ for two years. She is amenorrhoeic and denies any symptoms of vaginal discharge or pelvic pain.\n\nHer cervical smear tests are up to date, and her last cervical smear was reported as normal. She is due her next one in 3 months time.\n\nWhat is the most appropriate management?",
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"explanation": "Difficulties in breastfeeding are common in the first few days and weeks. Women should be supported and encouraged to continue breastfeeding where possible.",
"id": "50016",
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"name": "She should switch to bottle feeding indefinitely",
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"explanation": "Ideally the women should continue either breastfeeding or expressing milk by hand to encourage further milk production.",
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"name": "She should stop breastfeeding for three days and re-attempt",
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"explanation": "There is no indication of abscess or breast pathology that merits imaging in this case.",
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"explanation": "This is the treatment for a thrush infection. There is no indication here of a thrush infection, and the discomfort is likely caused by poor attachment.",
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"explanation": "In most cases, nipple discomfort in the first few days is due to poor nipple attachment, in which case breastfeeding support can benefit.",
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"explanation": "# Summary\n \nBreastfeeding provides many health benefits for both infant and mother. It is recommended by the WHO for infants until 6 months, with continued breastfeeding alongside solid foods until age 2 or beyond. It provides key benefits to both infant and mother, such as immunity support and reduced disease risks. Despite this, many infants are not breastfed for the recommended duration. Common breastfeeding issues include nipple pain, engorgement, mastitis, and insufficient milk. Management often involves pain relief, continued breastfeeding, and antibiotics when necessary. For mothers who choose not to breastfeed, formula is a suitable alternative.\n\n# Definition\n\nBreastfeeding is the process of feeding an infant or young child with breast milk directly from the breast. It is advised by the World Health Organisation (WHO) that an infant is exclusively breastfed until 6 months, followed by gradual introduction of solid food and breastfeeding until age 2 or longer. \n \nBenefits of breastfeeding include:\n \n- To the infant:\n - Antibodies and protection against infection\n - Reduced atopic eczema and asthma \n - Reduced rates of obesity later in childhood\n- To the mother:\n - Reduced risk of diabetes mellitus and heart disease \n - Protective against breast and ovarian cancer\n\n# Epidemiology\n\nGlobally, nearly 66% of infants are not exclusively breastfed for the recommended 6 months – a rate that has not improved in 2 decades. Breastfeeding rates in the UK are low - approximately 34% of infants are breastfed at 6 months. \n\n# Common issues\n \n- Cracked/sore nipples: pain, discomfort, visible cracks or sores on nipples.\n- Blocked duct and breast engorgement: pain, swelling, warmth, redness, lump in the breast.\n- Mastitis/abscess: fever, intense breast pain, red, swollen, warm breast, malaise, pus or discharge from the nipple.\n - This can be managed using antibiotics and analgesia\n- Thrush: white patches on the tongue or inside of the mouth, pain, discomfort, and difficulty feeding.\n- Insufficient milk: slow weight gain, fewer than six wet diapers a day, persistent hunger, no night feeds \n\n# Investigations\n \nFor any individual with breastfeeding problems:\n \n - Take a breastfeeding history and complete the UNICEF UK Baby Friendly Initiative Breastfeeding assessment form \n - A health visitor or breastfeeding specialist may be needed to observe to ensure optimal breastfeeding technique \n - Consider skin swab or breast milk sample for microscopy and culture if suspected bacterial or candida infection is present \n\n# Management \n\nManagement of problems with breastfeeding may include:\n\n- For breast engorgement and blocked ducts:\n - Encourage continued breastfeeding\n - Analgesia (see below) and warm compress for pain relief \n - Wear comfortable and non-restrictive clothing \n- For mastitis or breast abscess:\n - Manage conservative management as for breast engorgement \n - Breastfeeding should be encouraged \n - Oral antibiotics can be used for symptoms not improving after 12-24 hours or if breast milk culture is positive \n- For nipple damage:\n - Consider review by health visitor for advice and support \n - Consider ankyloglossia (tongue tie) in infant \n- For low milk supply:\n - Reassure the mother and manage any underlying cause (i.e. stress, hypothyroidism)\n - If continuing or concerns about the child's growth, refer for further treatment and investigations\n- Milk oversupply\n - Encourage breastfeeding\n - Avoid expressing milk by hand or breast pump between feeds to reduce overstimulation \n\n# Medications and Breastfeeding\n \n## Antibiotics\n \n\n - Antibiotics that are **safe** to use in breastfeeding mothers include: penicillin-based antibiotics, beta-lactam antibiotics, trimethoprim, azithromycin, cephalosporins, clarithromycin, erythromycin\n - IV gentamicin and meropenem can also be given\n - Tetracyclines although previously contraindicated - may be given in short courses, however, caution is advised\n - Most antibiotics can produce excessively loose motions in the baby, with the appearance of diarrhoea. Some infants appear more unsettled with tummy aches or colic. These effects are not clinically significant and do not require treatment.\n - Antibiotics which are **cautioned** or **contra-indicated** include: ciprofloxacin (potential joint problems), nitrofurantoin (G6PD deficiency), teicoplanin, clindamycin (antibiotic-associated colitis), co-trimoxazole. \n \n\n## Analgesia\n \n - Paracetamol and ibuprofen form the basis for safe analgesics for breastfeeding mothers.\n - NSAIDs are safe to use in breastfeeding mothers. \n - Stronger drugs are available but should be taken with caution and babies observed for drowsiness.\n - Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as a drug after caesarean section.\n \n - Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.\n - Codeine is no longer recommended as routine medication for breastfeeding mothers (MHRA June 2013, BNF) with particular caution where the mother has never taken the drug before or has found that the drug causes her to be drowsy, dizzy or experience severe constipation.\n \n\n## Alcohol and breastfeeding\n \nBreastfeeding mothers can have occasional, small amounts of alcohol but should not drink regularly or heavily (e.g. binge drinking) without considering how to limit the baby’s exposure.\n\n\n# Infection Transmission and Breastfeeding \n\n## HIV transmission\n \n\n - An HIV-infected mother can pass HIV to her infant during pregnancy and delivery \n - Anti-retroviral drugs reduce the risk of transmission of HIV through breastfeeding\n - However, current recommendations advise that HIV-infected mothers should refrain from breastfeeding \n \n\n## Hepatitis B transmission\n \nThere is no risk for mother-to-child transmission of Hepatitis B provided the infant has received appropriate HBV vaccination after birth and the nipples are not cracked or bleeding. \n\n# Alternatives\n\nFor mothers who prefer not to breastfeed, there are multiple types of formula available. Infants must have first infant formula when under 6 months, and that follow-on formula can only be used over the age of 6 months. It is important that infants under 1 year should not be given cow's milk as a drink alone, but can be used in cooking. \n \n \n# NICE Guidelines\n \n[NICE Guidelines on Breastfeeding problems](https://cks.nice.org.uk/topics/breastfeeding-problems/) \n\n# References \n \n[Patient Info on Infant Feeding](https://patient.info/doctor/infant-feeding)\n\n[WHO Health Topics on Breastfeeding](https://www.who.int/health-topics/breastfeeding#tab=tab_1)\n\n[Breastfeeding Network Drugs Factsheets](https://www.breastfeedingnetwork.org.uk/drugs-factsheets/)\n\n[NHS Types of formula](https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/bottle-feeding/types-of-formula/)",
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"question": "A 24-year-old woman calls her general practice with problems breastfeeding. She is three days postpartum, having delivered a baby boy by spontaneous vaginal delivery.\n\nShe describes both nipples as painful and it's uncomfortable for her to breastfeed. There is no unusual nipple discharge, swelling or redness, and the skin is intact. She is otherwise well.\n\nWhat is the most appropriate advice?",
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"explanation": "Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.",
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"explanation": "Whilst the scenario suggests this woman had a perineal tear that required suturing, this is a less likely cause for secondary postpartum haemorrhage. Perineal tears can become infected, however would be unlikely to cause abdominal pain and nausea.",
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"explanation": "Abnormal involution of the placental site is a rare cause of secondary postpartum haemorrhage and describes the abnormal persistence of patent spiral arteries following delivery. This can present with profuse secondary postpartum haemorrhage.",
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"explanation": "Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.",
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"comment": "wouldn't the absence of fever rule out endometritis? I would have thought retained products of conception would be more likely",
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"comment": "high WCC\n",
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"comment": "I thought it would be RPOC causing endometritis? Couldn’t this be the case?",
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"explanation": "# Summary\n\nPostpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery. The primary causes are uterine atony, birth canal injury or tear, retained placental or foetal tissue, and coagulopathies. Risk factors include a previous PPH, high BMI, multiple pregnancies, advanced maternal age, and more. Initial management involves resuscitation with an ABCDE approach and potentially activating a major haemorrhage protocol. Further management strategies may include rubbing the uterus, medication, or surgical treatment. Secondary PPH refers to bleeding from 24 hours to 12 weeks postpartum, typically caused by retained products of conception or endometritis. \n\n\n# Definition\n\n\n\nPostpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery.\n\n\n# Aetiology\n\n\nThe aetiology of postpartum haemorrhage (PPH) can be remembered using the mnemonic of the 4 'T's: \n\n- Tone: The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.\n\n- Trauma: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries.\n\n- Tissue: Retained placental or foetal tissue can cause continued bleeding.\n\n- Thrombin: Coagulopathies can lead to continued bleeding due to a failure of clotting.\n\n# Risk Factors\n\nRisk factors for postpartum haemorrhage (PPH) include:\n\n- PPH in previous pregnancy\n- BMI >35\n- Multiple pregnancy\n- Parity >4\n- Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia\n- Delivery via Caesarean section\n- Induction of labour\n- Instrumented delivery (forceps or ventouse) and episiotomy\n- Prolonged labour (greater than 12 hours)\n- Macrosomia (>4kg baby)\n- Advanced maternal age\n\n\n# Investigations\n\n\nInvestigations for PPH include blood tests for Group/Save and Crossmatch, and consideration of fresh frozen plasma if clotting abnormalities are present. In cases of secondary PPH, ultrasound looking for retained products and endocervical/high vaginal swabs looking for infection are recommended.\n\n# Management\n\n\nInitial management of PPH involves:\n\n- Resuscitation with an ABCDE approach\n- Consideration of activation of a major haemorrhage protocol\n- Laying the woman flat \n- Inserting two large bore cannulas\n- Providing oxygen\n- Considering fresh frozen plasma if clotting abnormalities are present\n\nFurther management strategies may include:\n\n- Mechanical methods such as rubbing the uterus and catheterisation\n- Medical treatments including oxytocin, syntocinon, ergometrine, carboprost, misoprostol, and tranexamic acid\n- Surgical treatments such as intrauterine balloon tamponade, B-lynch suture around the uterus, uterine artery ligation, or hysterectomy \n\nFor secondary PPH, management depends on the cause and can include surgical evacuation for retained products of conception or antibiotics for infection.\n",
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"question": "A 25-year-old woman, eight days postpartum after an uncomplicated vaginal delivery, presents with lower abdominal pain, heavy lochia (using 1-2 pads/hour), and nausea, expressing concern about the thickness of her discharge.\n\n\n\nOn examination, her abdomen is soft, uterus normally involuted, with tenderness in the lower abdomen.\n\n\n\n\nA gentle speculum examination reveals copious thick bloody discharge, with an offensive smell.\n\n\n\nHer observations are: heart rate 122 bpm, blood pressure 110/76 mmHg, respiratory rate 16 breaths/min, oxygen saturation 100% on room air, and temperature 37.1°C. \n\n\n\nHer full blood count test results are as follows:\n\n\n\n||||\n|--------------|:-------:|---------------|\n|Haemoglobin|79 g/L|(M) 130 - 170, (F) 115 - 155|\n|White Cell Count|16.5x10<sup>9</sup>/L|3.0 - 10.0|\n|Platelets|402x10<sup>9</sup>/L|150 - 400|\n\n\n\n\nWhat is the most likely source of her vaginal bleeding?",
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"explanation": "Transvaginal ultrasound scan should be requested for cases of new menorrhagia, looking for underlying causes such as fibroids or polyps. In this age group, fibroids are the most common cause of menorrhagia.",
"id": "50022",
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"explanation": "Mirena coil is licensed for management of heavy menstrual bleeding, however it is important to rule out pathology first.",
"id": "50023",
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"explanation": "Whilst the contraceptive implant can cause prolonged bleeding, this is a less likely underlying reason for new menorrhagia.",
"id": "50026",
"label": "e",
"name": "Removal of the progestogen-only subdermal implant",
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"explanation": "An endometrial biopsy may be indicated if the transvaginal ultrasound shows a thickened endometrium, however the first-line investigation is an ultrasound.",
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"explanation": "Tranexamic acid can be used for management of menorrhagia, however it is important to investigate for underlying pathology with a transvaginal ultrasound scan.",
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"explanation": "# Summary\n \n \nMenorrhagia is defined as excessive menstrual bleeding that significantly impacts a woman's quality of life. It is often characterised by heavy or prolonged menstrual periods and may result in iron deficiency anaemia. There is no set cut-off when defining menorrhagia: it is the patient who determines if bleeding is heavy to them or not. However, thorough clinical evaluation, including a full blood count, clotting studies, and possibly a transvaginal ultrasound, is necessary to identify potential underlying causes. Management strategies largely depend on the cause and may involve medical treatments like the Mirena® coil, mefenamic acid, tranexamic acid, hormonal contraceptives, or surgical interventions in refractory cases.\n \n \n# Definition\n \n \nMenorrhagia is a clinical condition defined as excessive blood loss during a menstrual period to an extent that it substantially affects a woman's quality of life.\n \n \n# Epidemiology\n \n \nMenorrhagia is a common gynaecological complaint. In about half of cases, no underlying pathology is found, and the condition is referred to as dysfunctional uterine bleeding.\n \n \n# Aetiology\n \n \nThe aetiology of menorrhagia can be categorised into two groups: local and systemic. \n \nLocal causes include:\n \n - Fibroids\n - Adenomyosis\n - Endometrial polyps\n - Endometriosis\n - Pelvic inflammatory disease\n - Endometrial cancer (be highly suspicious of this if there is postmenopausal bleeding)\n \n \nSystemic causes encompass:\n \n \n - Bleeding disorders\n - Hypothyroidism\n - Liver and kidney disease\n - Obesity\n \n \n# Signs and Symptoms\n \n \nThe primary symptom of menorrhagia is **heavy or prolonged menstrual bleeding**. \n\nHowever, other associated signs and symptoms may be present, depending on the underlying cause (see differential diagnosis). If severe enough, menorrhagia can also cause anaemia, which would present with **fatigue, weakness, shortness of breath and palpitations.**\n\n\n \n \n# Differential Diagnosis\n \n \nThe differential diagnosis for menorrhagia includes conditions that cause abnormal uterine bleeding. These may include:\n \n \n - **Fibroids:** Often asymptomatic, but can cause heavy or prolonged periods, pelvic pain or pressure, and frequent urination.\n - **Adenomyosis:** Symptoms can include prolonged, heavy menstrual bleeding, severe menstrual cramps, and pain during intercourse.\n - Endometrial polyps: Can cause irregular menstrual bleeding, bleeding between periods, excessively heavy periods, or postmenopausal bleeding.\n - **Endometrial cancer:** Symptoms include abnormal vaginal bleeding, pelvic pain, and pain during intercourse.\n- **Hypothyroidism:** Causes fatigue, weight gain and constipation.\n- **Clotting disorders:** Leads to excessive bleeding from minor injuries. \n \n \n# Investigations\n \n \nThe investigation of menorrhagia should include:\n \n**Bedside:**\n\n- Speculum and bimanual examination: This helps rule out causes such as cervical ectropion, or to investigate fibroids by feeling pelvic masses. \n\n**Bloods:**\n\n- FBC and iron studies: To rule out anaemia. \n- LFTs and clotting screen: To rule out liver and clotting disorders. \n- TFTs, if clinically indicated: To rule out hypothyroidism. \n\n**Imaging:**\n\n- Transvaginal ultrasound: To identify underlying causes such as fibroids or endometrial polyps.\n\n \n# Management\n \n \nThe management of menorrhagia largely depends on the underlying cause. If an underyling cause is found, the primary management involves treatment of that cause. \nOtherwise, if the cause is dysfunctional uterine bleeding, potential treatments include:\n \n**Medical:**\n\n - Mirena® coil: This is first line and most effective treatment option for menorrhagia. \n\nOtherwise:\n \n - Mefenamic acid: NSAID that prevents bleeding and helps relieve pain. \n - Tranexamic acid: Reduces bleeding but no effect on pain. \n - Combined oral contraceptive pill: Reduces bleeding, particularly helpful if the patient also requires contraception. \n\n**Surgical:**\n\n- Endometrial ablation (will require ongoing contraception)\n- Hysterectomy \n \nThese options are only applicable in rare cases refractory to medical management. \n \n\n# Complications\n\n- Anaemia: Occurs if bleeding is sufficiently severe.\n- Low mood, including depression and anxiety: The welfare and social complications (e.g. interference with work and social life) can have significant mental health impacts. \n\n# NICE Guidelines\n \n \n[Click here for more information on menorrhagia](https://cks.nice.org.uk/topics/menorrhagia/)\n \n# References\n\n[BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/171)\n\n[Patient Info](https://patient.info/doctor/menorrhagia)",
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"question": "A 44-year-old woman attends her general practitioner troubled by recent heavy periods. She describes her cycle as a regular 40-day cycle, with 7-10 days of bleeding. She has a progestogen-only implant as contraception, and has no past medical history of note.\n\nHer smear tests are up to date, and she has no concerns about sexually transmitted infection.\n\nWhat is the most appropriate management?",
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"explanation": "Vulvovaginal candidiasis is one of the most common causes of vaginal itch, however does not typically cause changes in the architecture of the vulva. With vulvovaginal candidiasis, a thick, lumpy discharge is usually evident.",
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"explanation": "Lichen sclerosus is an inflammatory skin condition that presents with itch and soreness. The tissues can lose their normal architecture, the introitus can become narrowed, and the labia minora and clitoral hood can become fused, burying the clitoris itself. The tissues appear pale and white, and fissuring or erosions may be evident. Lichen sclerosus is associated with other atopic conditions such as asthma and eczema.",
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"explanation": "Whilst premature ovarian failure can cause the vulva to appear white and atrophied, and also may cause dyspareunia, the tissues do not tend to become fused. In addition, she does not complain of any other symptoms of premature ovarian failure.",
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"explanation": "Vaginismus occurs when the pelvic floor muscles involuntarily spasm with touch or penetration. Whilst this can cause dyspareunia, it would not cause the changes seen in the vulval skin.",
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"explanation": "Lichen planus presents in a similar way to lichen sclerosus; however, lichen planus involves the mucous membranes such as the vagina as well as the skin. The usual presentation is with white or purple raised plaques.\n\nLichen planus is characterised by the 6 Ps:\n\n- Purple\n- Pruritic (itchy)\n- Polygonal (multiple sides)\n- Planar (flat-topped)\n- Papules/plaques",
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"explanation": "# Summary\n \n \nLichen sclerosus is an inflammatory skin condition that predominantly affects the genital and anal areas, characterized by white patches which may scar. It frequently presents itself with symptoms of itchiness and pain, and is more common in females than males. Key investigations for this condition include clinical evaluation, skin biopsy, and possibly blood tests. Management strategies often include topical steroids, avoidance of soaps in affected areas, and use of emollients to alleviate dryness and itching.\n \n \n# Definition\n \n \nLichen sclerosus is an inflammatory dermatological condition. It predominantly affects the genital and anal regions of the body, but it can present elsewhere. There is a noted predilection for this condition in females compared to males. The subtype, vulvar lichen sclerosus, specifically involves the inner vulva.\n \n \n# Aetiology\n \n \nThe cause of lichen sclerosus is currently unknown, but it is likely multifactorial. Potential contributing factors could include autoimmune reactions, genetic predisposition, and hormonal factors. Some studies suggest a possible link with previous skin damage or trauma.\n \n \n# Signs and Symptoms\n \n \n- White patches on the skin which may progress to scarring. \n- Itchiness and pain over patches, which may be exacerbated during urination or sexual intercourse.\n- Bleeding over patches, especially following sexual intercourse or passing of bowel motions. \n \n \n \n \n# Differential Diagnosis\n \n \nThe differential diagnosis for lichen sclerosus includes other dermatological conditions such as:\n \n \n - Lichen planus: Characterised by purple-looking, itchy, flat-topped bumps, and white lacy patches in the mouth or on the skin.\n \n - Psoriasis: Manifests as red patches with silver scales, typically on the scalp, elbows, knees, and lower back.\n \n - Vitiligo: Presents as patchy loss of skin color, usually first on sun-exposed areas of the skin.\n \n \n# Investigations\n \n**Bedside:**\n\n- Vulval examination: This should be enough to diagnose lichen sclerosus, if characteristic lesions are present. \n\n\nNo **blood tests** are required for diagnosis, but may on occasion be used to rule out other autoimmune conditions if there is clinical uncertainty. However, keep in mind that serology for autoimmune conditions often has low specificity. \n\nNo **imaging** is required.\n\n**Invasive:**\n\n- Skin biopsy: May be used to confirm the diagnosis. \n \n \n# Management\n \n \nThe management of lichen sclerosus includes:\n \n **Conservative:**\n \n - Avoidance of soaps in the affected areas to prevent further irritation.\n - Avoid tight clothing, rubbing or scratching. \n - Topical emollients to relieve dryness and soothe itching. \n \n**Medical:**\n\n\n - Topical corticosteroids (most often potent steroids, such as dermovate) to reduce inflammation and itching.\n - Topical cacineurin inhibitors (e.g. Tacrolimus) may be used in addition to steroids. However, they can cause burning and discomfort in the first few days of application. \n - Topical oestrogen cream or pessaries for postmenopausal women affected by atrophic vulvovaginitis, caused or exacerbated by scarring of lesions. \n - Oral treatment with corticosteroids, retinoids, methotrexate or ciclosporin may be indicated in severe cases that do not respond to topical therapies. \n\n**Surgical:**\n\nWhilst surgical management is not usually performed, it can be used in cases of severe adhesions and advanced scarring that impacts continence and sexual intercourse, where conservative and medical measures have not helped.\nSurgery would also be indicated in cases of squamous cell carcinoma (see complications). \n\n\n# Complications\n\n- Infections: Namely Candida albicans, Staphylocuccus aureus, Herpes simplex, predisposed by breaks in the skin. \n- Squamous cell carcinoma: Affects up to 5% of patients with vulval lichen sclerosus. \n- Worsening constipation: Often as a result of pain or discomfort while passing bowel motions. \n \n \n# NICE Guildelines\n\n[Click here for NICE Guildelines on assessment of vulval itching](https://cks.nice.org.uk/topics/pruritus-vulvae/diagnosis/assessment/)\n\n\n# References\n \n \n[BASHH 2014 UK National Guideline on the Management of Vulval Conditions](https://www.bashh.org/documents/UK%20national%20guideline%20for%20the%20management%20of%20vulval%20conditions%202014.pdf)\n\n[DermNet](https://dermnetnz.org/topics/lichen-sclerosus)\n\n[NHS UK](https://www.nhs.uk/conditions/lichen-sclerosus/)",
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"question": "A 35-year-old woman attends her general practitioner with difficulties during penetrative sex. She describes painful penetration, which feels superficial. In addition, she states her vulva is always itchy, and she has used several over the counter thrush remedies without resolution of symptoms.\n\nShe had a spontaneous vaginal delivery two years ago, and has a past medical history of asthma which is treated with an inhaled corticosteroid inhaler.\n\nOn examination, her vulva generally appears pale, with some fissuring around the introitus. The clitoris is not visible. Digital vaginal examination is painful, and a gentle speculum examination reveals a normal vaginal mucosa with a thin, white non-odorous discharge present.\n\nWhat is the most likely underlying cause of her symptoms?",
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"explanation": "Cervical cerclage is the placement of a suture into the cervix of a pregnant woman where there is premature shortening of the cervix, with an aim to prolong gestation.",
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"explanation": "Hymenectomy is a surgical procedure to open the hymen to allow for the passage of menstrual blood and sexual intercourse. It is often necessary for people born with an imperforate hymen, or who have a septate hymen.",
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"explanation": "Deinfibulation refers to a surgical procedure to restore the vaginal introitus in women who have undergone type III female genital mutilation (infibulation, or surgical closure/narrowing of the vaginal introitus).",
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"explanation": "Insertion of a balloon catheter (often referred to as a Word catheter) is one of the preferred management strategies for symptomatic Bartholin's cyst abscess. Under local anaesthesia, a stab incision is made into the labia minora, over the abscess, and the contents of the abscess drained. A balloon catheter is then inserted into the cyst cavity and the balloon inflated with 2-4mL of saline. A suture may be placed to keep the catheter in place. The catheter remains in place for up to 4 weeks to allow epithelialisation of the tract to occur.",
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"explanation": "# Summary\n \n \nBartholin's glands are located within the vestibule, lateral to the introitus, and function to secrete a lubricating fluid. A Bartholin's cyst develops when the gland's duct becomes blocked, causing palpable swelling and pain at the gland site. If a cyst becomes infected, it evolves into a Bartholin's gland abscess. Key investigations include physical examination, ultrasound, biopsy, and sometimes culture of the fluid. Management strategies range from conservative treatment like warm salt baths for pain relief, antibiotics in cases of abscess, to more invasive procedures like incision and drainage or other surgical intervention in recurrent cases.\n \n \n# Definition\n \n \nBartholin's glands are situated within the vestibule, just lateral to the introitus, and their primary function is to secrete a lubricating fluid. \nPathologies associated with these glands include:\n \n \n - Bartholin's gland cyst: This occurs when the duct from the gland becomes blocked, resulting in palpable swelling and pain at the site of the Bartholin's gland.\n - Bartholin's gland abscess: This occurs when a cyst becomes infected, resulting in extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset.\n \n \n# Epidemiology\n \n \nBartholin's gland cysts and abscesses are common gynaecological issues. Data suggests that these conditions are most prevalent in women of reproductive age, typically between 20-30 years old.\n \n\n# Aetiology\n \n \nThe primary cause of Bartholin's gland cysts and abscesses is the blockage of the gland's duct. This blockage can be due to thick mucus, inflammation, trauma, or in rare cases, malignancy. Abscesses are typically caused by infection of a cyst, often with normal vaginal flora or sexually transmitted bacteria.\n \n \n# Signs and Symptoms\n \n \n - Bartholin's gland cyst: Palpable swelling and pain at the site of the Bartholin's gland.\n - Bartholin's gland abscess: Extreme pain, lymphadenopathy, erythema, and in rare cases, systemic upset such as fever and malaise.\n \n \n# Differential Diagnosis\n \n \n - **Vaginal cysts:** Typically asymptomatic but can cause discomfort during sex or when sitting.\n - **Skene's duct cysts:** Located on either side of the urethra, can cause discomfort during sex or urination.\n - **Vulvar cancer:** Can present with a vulvar lump, itching, pain, or abnormal bleeding.\n \n \n# Investigations\n \n**Bedside:**\n\n - Physical examination: To assess the size, location, and nature (cystic or solid) of the swelling.\n\n**Bloods:**\n\n - Culture: In cases of abscess to identify the causative organism.\n - FBC, CRP: Markers of inflammation . \n\n **Invasive:**\n \n - Ultrasound: To confirm the diagnosis and rule out other potential causes of vulvar swelling.\n - Biopsy: In postmenopausal women or in cases where malignancy is suspected.\n\n \n \n# Management\n\n**Conservative:**\n \n - Warm salt water baths: To relieve pain.\n\n\n**Medical:**\n \n - Antibiotics: Used in cases of abscess to treat the underlying infection.\n\n**Surgical:**\n \n - Incision and drainage: Under local anaesthetic, the swollen gland is incised and allowed to drain. A Word catheter may also be inserted to promote continued drainage.\n\n\n \n \n# NICE Guidelines\n[Click here for NICE guidelines](https://www.nice.org.uk/guidance/ipg323)",
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"explanation": "For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU anti-D Ig prophylaxis should be administered within 72 hours of the event. A test for FMH is not required.",
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"explanation": "# Overview\n\nThe D antigen is found on red blood cells and is an important antigen in the rhesus factor system.\n\nRhesus isoimmunisation can occur when a rhesus negative mother has a baby which is rhesus positive. If any foetal red blood cells enter the maternal circulation, the mother will form anti-D antibodies against them.\n\nThe maternal anti-D antibodies can cross the placenta in subsequent pregnancies and cause Rhesus haemolytic disease if the future baby is rhesus positive.\n\n# Sensitisation events\n\n“Sensitisation” events are events which cause foetal blood to cross the placenta into the maternal circulation and thus these are indications for anti-D prophylaxis.\n\nExamples of sensitisation events include:\n\n- Antepartum haemorrhage\n- Placental abruption\n- Abdominal trauma\n- External cephalic version\n- Invasive uterine procedures such as amniocentesis and chorionic villus sampling\n- Rhesus positive blood transfusion to a rhesus negative woman\n- Intrauterine death, miscarriage or termination\n- Ectopic pregnancy\n- Delivery (normal, instrumental or caesarean section)\n\n# Testing\n\nAll mothers should be tested for rhesus status and anti-D antibodies at booking\n\n# Management of the Rh-D negative mother\n\nPresence of anti-D antibodies can result in incompatibility and haemolysis in future pregnancies. To attenuate this risk, anti-D antibodies are given to patients who have experienced a sensitising event. Anti-D is also given to all non-sensitised Rhesus negative mothers at 28 weeks. Note that anti-D has no effect once sensitisation has already occurred (it is prophylactic only).",
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"question": "A 23-year-old primiparous woman attends accident and emergency following a head-on car collision in which she was driving. She is currently 19 weeks pregnant. She has sustained minor bruising to the abdomen and chest from the seatbelt, but otherwise has no injuries. The foetal heart is auscultated and foetal wellbeing confirmed. There is no vaginal bleeding. The woman is reported to be rhesus negative.\n\nWhat is the most appropriate management?",
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"explanation": "This is unlikely to have a significant benefit over her current regime. The management of likely endometriosis aside from analgesia aims to reduce menstrual bleeding and induce amenorrhoea.",
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"explanation": "This woman likely has endometriosis, as evidenced by the cyclical pain. Contraceptives likely to induce amenorrhoea are likely to be most beneficial in the medical management. Medroxyprogesterone acetate is likely to induce amenorrhoea, with over 70% of users amenorrhoeic after a year of use.",
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"comment": "So I get the answer - but. what do we do with the COCP? Will she stay on it? do people go on both depo + COCP?\nPatient.info suggests that we should either change the COCP formulation OR try a different contraception. so in this question would it be better for the option to say ''switch to depo'' instead? ",
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"comment": "i agree, thats why i went for mefenamic acid as didnt know if she could be on two forms at the same time?\n",
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"comment": "Is mefenamic acid more effective than ibuprofen for dysmenorrhoea? If ibuprofen has not been working for a pt's dysmenorrhoea, do we stop ibuprofen and prescribe mefenamic acid instead? Or do we move on to second-line management, such as COCP? ",
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"explanation": "# Summary\n \nEndometriosis is a condition characterised by the growth of endometrial tissue outside the uterine cavity. The principal symptoms include dysmenorrhoea, dyspareunia, and subfertility. Gold standard for diagnosis is a diagnostic laparoscopy, with treatment dependent on the severity of symptoms and ranging from analgesia and hormonal therapies to surgical intervention.\n \n \n# Definition\n \n \nEndometriosis is a gynaecological condition where endometrial tissue, which typically lines the uterus, proliferates outside the uterine cavity.\n \n \n# Epidemiology\n \n \nAlthough the exact prevalence is unknown due to often asymptomatic or non-specific presentation, endometriosis is estimated to affect approximately 10% of women in their reproductive years.\n \n \n# Aetiology\n \n \nThe exact cause of endometriosis is unclear, but several theories exist including retrograde menstruation, coelomic metaplasia, and lymphatic or vascular dissemination of endometrial cells.\n \n \n# Signs and Symptoms\n \n \nPatients with endometriosis often present with the following symptoms:\n \n \n - Dysmenorrhoea\n - Dyspareunia\n - Subfertility\n - Dyschezia or haematochezia (uncommon), if colorectal tract is affected\n - On pelvic examination, tender, nodular masses (endometriomas) may be palpable on the ovaries or the ligaments surrounding the uterus. \n - Fixed-retroverted uterus on examination \n \n \n# Differential Diagnosis\n \n \nThe primary differentials for endometriosis include other causes of dysmenorrhoea:\n \n \n - **Primary dysmenorrhoea:** characterised by crampy pelvic pain at the onset of menses with no identifiable pelvic pathology.\n - **Uterine conditions** (e.g. fibroids, adenomyosis): these can cause heavy menstrual bleeding and pelvic discomfort. Would be visible on TV USS and/or MRI. \n - **Adhesions:** pelvic pain and possible bowel obstruction. Usually seen in women who have had previous pelvic surgery or PID. \n - **Pelvic inflammatory disease (PID):** presents with lower abdominal pain, fever, abnormal vaginal discharge, and possible dyspareunia.\n \n \n# Investigations\n \n \nThe following diagnostic tools are commonly used in the diagnosis of endometriosis:\n\n**Bedside:**\n\n- Bimanual examination: fixed, retroverted uterus; may feel endometriomas (small masses) \n \n**No blood tests** are specifically indicated for endometriosis. \n\n\n**Imaging:**\n\n- Transvaginal ultrasound: Often normal, but may identify an ovarian endometrioma, a cyst made of endometrial tissue in the ovary.\n- MRI: Greater sensitivity than TV USS. \n\n\n**Invasive:**\n\n - Diagnostic laparoscopy: Considered the gold standard diagnostic tool, but it carries a small risk of complications (e.g. bowel perforation) and is not the first-line investigation. The procedure may be used for diagnosis and treatment in one go. \n \n \n# Management\n \n \nManagement strategies for endometriosis are predominantly symptom-based and range from medication to surgical interventions:\n\n**Medical:**\n \n - Analgesia: Paracetamol or non-steroidal anti-inflammatory drugs\n - Hormonal therapies: Combined oral contraceptive pill, medroxyprogesterone acetate, gonadotrophin-releasing hormone agonists\n \n**Surgical:**\n\n - Ablation or excision of lesions\n - Ovarian cystectomy (for endometriomas)\n - Bilateral oophorectomy (sometimes with a hysterectomy)\n \n \nIn cases where endometriosis is causing infertility, menstrual suppression would be unsuitable, and so ablation or excision of lesions (surgery) is more appropriate.\n \n \n# Complications\n\n- Infertility: Possible complication of excision of endometrioma from ovary, or as a result of the endometriomas themselves. \n- Adhesion formation: Complication of surgery. \n- Epithelial cell ovarian cancer: Women with endometriosis have twice as high a chance of developing this malignancy. \n \n# NICE Guidelines\n \n \n [Click here for NICE CKS on endometriosis](https://cks.nice.org.uk/topics/endometriosis/)\n \n# References\n [BMJ Best Practice](https://bestpractice.bmj.com/topics/en-gb/355/history-exam)",
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"question": "A 28-year-old woman attends her general practitioner with painful periods. She describes a 7-year history of pain in her lower abdomen and back alongside her period each month. She was commenced on the combined oral contraceptive pill (COCP) six months ago and advised to take this using an extended regime, having a withdrawal bleed once every three months.\n\nShe is having trouble with breakthrough bleeding with the COCP, and is still experiencing significant pain. She is taking ibuprofen 400mg three times daily, co-codamol 30/500 two tablets four times per day, and often requires time off work due to the intensity of the pain.\n\nWhat is the most appropriate next step in the management of this patient?",
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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 |
173,458,779 | false | 2 | null | 6,494,974 | null | false | [] | null | 10,054 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "This child is 8 and can probably take tablets, but when is it generally preferred to give medications as an oral suspension to children? ",
"createdAt": 1737483012,
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"id": "61167",
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"replies": [
{
"__typename": "QuestionComment",
"comment": "I've been told by some FYs generally when they're 11-12 you can expect them to be able to swallow + comply",
"createdAt": 1737489933,
"dislikes": 0,
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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": "3587",
"name": "Prescribing antibiotics for otitis media",
"status": null,
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"name": "Paediatrics",
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"explanation": "## Drug choice feedback\n\nThis patient has otitis media, this can be inferred due to the otalgia, otorrhoea and findings on examination. The first line treatment for otitis media in children is amoxicillin. If the patient has a penicillin allergy then you should prescribe clarithromycin.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's ear infection:\n\n- Amoxicillin 500mg PO TDS 5-7 days",
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"question": "Case Presentation: A 8-year-old boy is brought to the GP by his mother due to otalgia. This is affecting his right ear, his hearing on this side is 'muffled' according to his mother. \n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## On examination\n\nTemperature 37.2°C, HR 98, RR 22, BP 111/68, O<sub>2</sub> 99% RA, GCS 15, Weight 25kg\n\nThere is a yellow, purulent discharge from his right ear.\n\nOtoscopy: injection of blood vessels on the tympanic membrane and diffuse erythema of the mid ear. There is a small perforation in the roof of the tympanic membrane.\n\nNo neurological abnormalities detected. No signs of mastoiditis.\n\n## Investigations\n\nNil\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his otitis media.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,458,780 | false | 3 | null | 6,494,974 | null | false | [] | null | 10,052 | {
"__typename": "QuestionPrescription",
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"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "2657",
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},
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"demo": null,
"entitlement": null,
"id": "3585",
"name": "First-line hypertension management in patients >55 years old",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
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},
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"explanation": "## Drug choice feedback\n\nThis gentleman has hypertension. This is confirmed based on the readings at the GP and the at home readings he has measured himself. As he is older than 55 years of age, the first line medication he should be prescribed is a calcium channel blocker.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe options to treat this gentleman's hypertension are as follows:\n\n- Amlodipine 5mg PO OD\n- Felodipine 5mg PO OD\n- Lacidipine 2mg PO OD\n- Lercanidipine hydrochloride 10mg PO OD\n- Nicardipine hydrochloride 20mg PO TDS",
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"question": "Case Presentation: A 67-year-old gentleman attends his GP for a blood pressure review. He had high blood pressure at a previous review and has returned with his home blood pressure monitoring.\n\n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## Investigations\n\nBlood pressure at previous visit: 151/88 mmHg\n\nBlood pressure at today's visit: 148/90 mmHg\n\nHome blood pressure reading average: 149/89 mmHg\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his hypertension.",
"sbaAnswer": null,
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} | MarksheetMark |
173,458,781 | false | 4 | null | 6,494,974 | null | false | [] | null | 10,058 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The answers on this mock have been incredibly confusing and inconsistent. How do we know the duration is 4 weeks???",
"createdAt": 1735904840,
"dislikes": 0,
"id": "59513",
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"__typename": "QuestionComment",
"comment": "if in the bnf it has said maximum 4 sachets, how do you know what frequency to put down ? ",
"createdAt": 1735912031,
"dislikes": 0,
"id": "59538",
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{
"__typename": "QuestionComment",
"comment": "and for duration - does it matter if you write down 1 month or 4 weeks",
"createdAt": 1735912071,
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{
"__typename": "QuestionComment",
"comment": "Why not \"to be reviewed\" \n",
"createdAt": 1736013333,
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{
"__typename": "QuestionComment",
"comment": "13.8g is an adult dose for a 4 year old. Paediatric sachets not an option on drop down list",
"createdAt": 1737379946,
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"explanation": "# Summary\n \n\nConstipation in children is defined as a condition where the child defaecates less than three times per week or experiences significant difficulty in passing stool. The typical signs and symptoms include hard, pellet-like stool that is difficult to pass, and in some cases, overflow diarrhoea. It's primarily diagnosed through patient history and abdominal examination. Management includes a Movicol disimpaction regimen followed by maintenance Movicol, a high-fibre diet, and fostering good toileting habits. \n \n\n# Definition\n \n\nConstipation in children is a clinical condition where the child defecates fewer than three times per week or experiences significant difficulty in passing stool. Chronic constipation in this population is often characterised by hard, pellet-like stool that is difficult to pass.\n \n\n# Epidemiology\n \n\nConstipation in children is a common occurrence, affecting 30% of children aged 4-11 years, however, the peak incidence is around age 2-3 when the child undergoes toilet training. It is likely under-reported as symptoms such as overflow diarrhoea may not be recognised as constipation by parents. \n \n\n# Aetiology\n \n\nThe most common cause of chronic constipation in children is dietary factors, with other contributing factors including:\n \n\n- Fever\n- A low-fibre diet and poor fluid intake \n- Family history of constipation \n- Avoidance of using the toilet\n- Pain upon passing stool, e.g., secondary to an anal fissure or very hard stool\n- Unrecognised sensation of needing to pass stool\n- Sedentary behaviour or impaired mobility \n\nThere is often a trigger for constipation:\n\n- Dietary changes \n- Toilet training \n- Social changes (starting nursery, moving house, fears, family changes)\n- Medications \n- Anal fissure \n \n\n# Signs and symptoms\n \n\nIn children, chronic constipation often presents as:\n \n\n - Hard, pellet-like stool that is difficult to pass\n - Possible overflow diarrhoea due to fluid moving past the hard stool in the rectum\n - Less than 3 stools passed per week \n - The child may have pain and straining during defaecation\n\nFor idiopathic constipation, the following red flags must be ruled out:\n\n- Delayed passage of meconium \n- Onset of constipation within first few weeks of life \n- Failure to thrive (faltering weight gain and growth)\n- \"Ribbon stools\"\n- Neurologic problems in lower limbs \n- Anal abnormalities \n\n\n# Differential diagnosis\n \n\n - **Hirschsprung's disease**: Presents with a delay in passing meconium (>48 hours), a distended abdomen, forceful evacuation of meconium after digital rectal examination, and a history of chronic constipation with poor response to Movicol disimpaction regimens and poor weight gain.\n - **Irritable Bowel Syndrome (IBS)**: May cause chronic constipation and is associated with abdominal pain, bloating, and altered bowel habits. Pain is typically relieved by defecation.\n - **Hypothyroidism**: Can lead to constipation, along with other symptoms such as weight gain, fatigue, cold intolerance, and slow growth in children.\n - **Celiac Disease**: While more commonly associated with diarrhoea, it can sometimes cause constipation. Other symptoms include failure to thrive, abdominal pain, and bloating.\n - **Lead poisoning**: Constipation is one of the symptoms along with learning difficulties, irritability, loss of developmental skills in children, and possibly anaemia.\n - **Anal fissure**: Pain during and after bowel movements can lead to constipation due to the child's fear of experiencing pain again.\n - **Functional constipation**: Characterised by normal anorectal and colonic physiology but the passage of hard stools, infrequent stools, or painful defecation.\n - **Neurological disorders** like Spina Bifida and Cerebral Palsy: These conditions may impact the nerves that control bowel function, leading to constipation.\n \n\n# Investigations\n \n\n- Chronic constipation is generally diagnosed from history and examination\n - Abdominal examination may reveal impacted faeces (hard, depressible masses) \n - Examination to exclude neurologic impairment in lower limbs or abnormal appearance of the anus which may indicate a diagnosis other than idiopathic constipation \n \nIf a specific diagnosis is queried or if the constipation is not responding to treatment, referral for further investigations by a specialist paediatrician is indicated. These include:\n\n- A rectal suction biopsy for Hirschsprung's disease.\n \n\n# Management\n \n\n- The initial treatment of chronic constipation is with a Movicol (polyethylene glycol 3350) disimpaction regimen.\n - If the child does not have faecal impaction, the child can be started on maintenance therapy first. \n - If the child does not respond to Movicol, a stimulant laxative can be added after 2 weeks. \n- This is followed by maintenance Movicol \n- Lifestyle management:\n - Encourage a high-fibre diet with sufficient fluid intake \n - Provide advice about encouraging good toileting habits (i.e. regular toilet times) \n - Regular physical activity \n- In the case of Hirschsprung's disease, definitive management is through the surgical removal of the section of the aganglionic colon. The healthy bowel is then pulled through.\n\n \n# Complications\n\nConstipation in children may lead to:\n\n - Anal fissures\n - Haemorrhoids \n - Rectal prolapse\n - Faecal impaction and overflow soiling \n - Psychological distress to the child \n \n \n# Prognosis \n\nEarlier detection and management of constipation in children is associated with an improved prognosis. For approximately 1/3 of children, the constipation becomes chronic. Following treatment, 60% of children become free from constipation by 1 year and 80% of children have no symptoms by age 16. \n\nComorbidities such as psychological disorders and psychosocial issues are associated with a generally poorer prognosis. \n \n\n# NICE Guidelines \n \n\n[NICE Guidelines on Constipation in Children](https://www.nice.org.uk/guidance/cg99)\n \n# References\n\n[NHS Constipation in children](https://www.nhs.uk/conditions/baby/health/constipation-in-children/) \n\n[Patient info Constipation in children](https://patient.info/digestive-health/constipation/constipation-in-children)",
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"explanation": "## Drug choice feedback\nThis child is suffering from constipation. There are no signs of faecal impaction and so a regular maintenance laxative should be prescribed.\n\nOsmotic (stool softening) laxatives are the first-line drug prescribed in children with constipation. The macrogol 'Movicol' (Polyethylene glycol 3350 plus electrolytes) or Lactulose are recommended as first-line treatment.\n\nStimulant laxatives such as Senna and sodium picosulphate should be used as second-line and so would not be appropriate in this instance.\n\n## Dose/Route/Frequency/Duration feedback\nMovicol is prescribed in sachets. The maintenance dose for a 4-year-old is 1 sachet daily.\n\nLactulose is a liquid prescribed in mL, the dose for a 4-year-old is 2.5-5mL twice daily.",
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"question": "Case Presentation: A 4-year-old boy is brought to the GP by his mother with abdominal pain and infrequent bowel movements. He has been passing 1-2 hard stools per week. His mother reports that he experiences pain when passing stools. He has a good diet and good fluid intake. He has reached all of his developmental milestones. \n\n\n## PH\nNone\n\n## DH\nNone\n\nNKDA\n\n## On examination\nThe patient looks well.\n\nOn palpation of the abdomen, there is generalised tenderness with no guarding and no palpable faecal mass.\n\nHeight: 100cm\n\nWeight: 16kg\n\n# Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat his condition.",
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"comment": "Should be able to give multiple versions of the same answer \nI put 1 week but its marked as wrong",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis gentleman has a gastric ulcer secondary to helicobacter pylori infection. He should therefore be prescribed triple therapy. Classically, triple therapy consists of a proton pump inhibitor, and two antibiotics - clarithromycin and amoxicillin. This patient has a penicillin allergy however so amoxicillin is replaced by metronidazole.\n\n## Dose/Route/Frequency/Duration feedback\n\n400mg BD for 7 days is the optimum dose of metronidazole to treat helicobacter (alongside the rest of the prescribed triple therapy).",
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"question": "Case Presentation: A 63-year-old gentleman attends his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.\n\n\n## PH\nObesity, hypercholesterolaemia, hypertension\n\n## DH\nAtorvastatin 40mg PO OD, ramipril 5mg PO OD.\n\nHe is allergic to penicillin.\n\n## FHx\n\nNo upper gastrointestinal cancer\n\n## On examination\n\nHe is alert and oriented. Upon palpation of the abdomen, there is epigastric tenderness, there are no other abnormalities.\n\nTemperature 36.9°C, HR 80, RR 16, BP 143/92mmHg O<sub>2</sub> 98% RA, GCS 15, Weight 106kg\n\n## Investigations\n\nFBC: Hb 146, WCC 5.2, Plt 328\n\n2ww OGD performed: \"Benign gastric ulceration noted, no oesophagitis, no masses seen.\"\n\nStool antigen test for _H. pylori_: positive\n\n## Prescribing Request\n\nIt is decided he should be started on triple therapy. He has already had omeprazole and clarithromycin prescribed.\n\nWrite a prescription for one drug that is most appropriate to treat his helicobacter pylori infection.",
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"comment": "am i missing something, the q said syringe driver so why are we prescribing s/c?",
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"comment": "syringe drivers are SC in palliative care",
"createdAt": 1675258455,
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"comment": "Syringe drivers are known as continuous subcutaneous injections CSCI",
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"comment": "Can Oxycodone be given in this case? (If the dosage and route is correct?)",
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"comment": "I do not see why not\n",
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"comment": "can you give 30 mg morphine twice a day?",
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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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"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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"value": 13,
"visible": false
},
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"__typename": "PrescribeAnswerData",
"label": "subcutaneous (SC)",
"value": 10,
"visible": false
}
},
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"__typename": "PrescriptionAnswer",
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"__typename": "PrescribeAnswerData",
"label": "40 mg",
"value": 343,
"visible": false
},
"drug": {
"__typename": "PrescribeAnswerData",
"label": "diamorphine hydrochloride 10 mg injection",
"value": 428,
"visible": false
},
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"__typename": "PrescribeAnswerData",
"label": "Continuous",
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"visible": true
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"__typename": "PrescribeAnswerData",
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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,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,458,784 | false | 7 | null | 6,494,974 | null | false | [] | null | 10,053 | {
"__typename": "QuestionPrescription",
"choices": [],
"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,
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"demo": null,
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"id": "3586",
"name": "Prescribing emergency oral contraception",
"status": null,
"topic": {
"__typename": "Topic",
"id": "66",
"name": "Obstetrics & Gynaecology",
"typeId": 5
},
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"dislikes": 22,
"explanation": "## Drug choice feedback\n\nThis patient is asking for emergency contraception in the form of a pill. There are two options you can prescribe - levonorgestrel or ulipristal acetate. Levonorgestrel is only effective if the episode of unprotected sex has occurred within 72 hours of presentation whereas ulipristal is effective up to 120 hours after the episode of unprotected sex.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescriptions would provide emergency contraception for this patient:\n\n- Levonorgestrel (Levonelle) 1.5mg PO ONCE\n- Ulipristal acetate (ellaOne) 30mg PO ONCE",
"highlights": [],
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"__typename": "PrescriptionAnswer",
"dose": {
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"label": "30 mg",
"value": 388,
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"question": "Case Presentation: A 19-year-old woman attends her GP asking for emergency contraception. She has had unprotected sex 48 hours ago. She does not want an invasive procedure or injection.\n\n\n## PH\nNil.\n\n## DH\nNil.\n\n## On examination\n\nNil.\n\n## Investigations\n\nNil.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to provide her with emergency contraception.",
"sbaAnswer": null,
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"typeId": 4,
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} | MarksheetMark |
173,458,785 | false | 8 | null | 6,494,974 | null | false | [] | null | 10,056 | {
"__typename": "QuestionPrescription",
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"comments": [
{
"__typename": "QuestionComment",
"comment": "Why not dabigatran?",
"createdAt": 1706299912,
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"id": "39918",
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"likes": 2,
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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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"displayName": "Recessive Myopathy",
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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,
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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": "2693",
"name": "Post-Operative Thromboprophylaxis ",
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"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
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},
"conceptId": 2693,
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"dislikes": 0,
"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.",
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"__typename": "PrescriptionAnswer",
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"__typename": "PrescribeAnswerData",
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"__typename": "PrescribeAnswerData",
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},
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"label": "aspirin 75 mg tablets",
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"value": 2338,
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},
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"label": "2 weeks",
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"visible": false
},
"frequency": {
"__typename": "PrescribeAnswerData",
"label": "twice daily (BD)",
"value": 11,
"visible": false
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"value": 6,
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"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 |
173,458,786 | false | 9 | null | 6,494,974 | null | false | [] | null | 10,061 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50051",
"label": "b",
"name": "Lymecycline;408mg;PO (Oral);Once daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
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"explanation": null,
"id": "50058",
"label": "i",
"name": "Paracetamol;1g;PO (Oral);PRN",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50053",
"label": "d",
"name": "Benzoyl Peroxide;1 Application;Topically;Once daily (after washing)",
"picture": null,
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},
{
"__typename": "QuestionChoice",
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"id": "50057",
"label": "h",
"name": "Propranolol;80mg;PO (Oral);Once daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50054",
"label": "e",
"name": "Rigevidon (Ethinylestradiol with Levonorgesterel);1 Tablet;PO (Oral);Once daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50055",
"label": "f",
"name": "Sumatriptan;100mg;PO (Oral) PRN for migraine;(max dose 300mg per day)",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50052",
"label": "c",
"name": "Adapalene;1 Application (thinly);Topically;Once nightly",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
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"id": "50056",
"label": "g",
"name": "Hydrocortisone cream;1 Application (thinly);Topically;Once daily",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50050",
"label": "a",
"name": "Aveeno cream;1;Application Topically;Twice daily",
"picture": null,
"votes": 0
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "i thought there is no evidence that COCP could cause weight gain, and the only one is the injection",
"createdAt": 1706189689,
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"id": "39823",
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{
"__typename": "QuestionComment",
"comment": "I'd like to see what the reasoning for this is too, almost everything I've read says there is no actual evidence for weight gain",
"createdAt": 1706446406,
"dislikes": 0,
"id": "40036",
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},
{
"__typename": "QuestionComment",
"comment": "Reassured that everyone else is on the same page RE the COCP",
"createdAt": 1706740654,
"dislikes": 1,
"id": "40425",
"isLikedByMe": 0,
"likes": 10,
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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": "Combined Oral Contraceptive pill; adverse reactions",
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"typeId": 5
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"explanation": "1. Rigevidon (Ethinylestradiol with Levonorgestrel) is a combined oral contraceptive pill (COCP). This patient suffers from migraine with aura. The COCP is contraindicated in patients with migraine with aura due to the increased risk of stroke.\n2. A common side effect of the COCP is weight gain.",
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"question": "Case presentation: A 23-year-old female attends the GP with migraines. \n\n\n**PH** Acne, Eczema, Anxiety, Migraines with aura.\n**DH** Her regular medicines are listed (below).\n\n**On Examination**\n\nTemperature 37.2°C, HR 84, RR 16, BP 124/78\nWeight 60kg\n\n**Investigations**\n\nNegative human chorionic gonadotrophin (HCG) pregnancy test\n\nQuestion 1: Select the ONE prescription that is contraindicated in this patient (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that is the most likely to cause weight gain (mark them with a tick in column B)",
"sbaAnswer": null,
"totalVotes": 0,
"typeId": 3,
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} | MarksheetMark |
173,458,787 | false | 10 | null | 6,494,974 | null | false | [] | null | 10,064 | {
"__typename": "QuestionMultiA",
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50084",
"label": "h",
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"picture": null,
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},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50078",
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"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50077",
"label": "a",
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"picture": null,
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},
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"__typename": "QuestionChoice",
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"id": "50079",
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},
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"__typename": "QuestionChoice",
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"id": "50080",
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"picture": null,
"votes": 0
},
{
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"explanation": null,
"id": "50085",
"label": "i",
"name": "Paracetamol;1g;PO;QDS",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50082",
"label": "f",
"name": "Salbutamol;200 micrograms;INH;QDS",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50083",
"label": "g",
"name": "Ibuprofen;400mg;PO;QDS",
"picture": null,
"votes": 0
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50081",
"label": "e",
"name": "Bisoprolol;5 micrograms;PO;OD",
"picture": null,
"votes": 0
}
],
"comments": [
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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",
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"name": "Apixaban can cause anaemia and a dosing error in bisoprolol",
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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).",
"sbaAnswer": null,
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173,458,788 | false | 11 | null | 6,494,974 | null | false | [] | null | 10,059 | {
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"id": "50039",
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"id": "50035",
"label": "d",
"name": "Carbamazepine;500mg;PO (Oral);Twice Daily",
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"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50033",
"label": "b",
"name": "Lisinopril;20mg;PO (Oral);Once Daily",
"picture": null,
"votes": 0
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{
"__typename": "QuestionChoice",
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"explanation": null,
"id": "50038",
"label": "g",
"name": "Prednisolone;15mg;PO (Oral);Once Daily",
"picture": null,
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"id": "50040",
"label": "i",
"name": "Folic Acid;5mg;PO (Oral);Once Weekly",
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"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 ",
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"comment": "Methotrexate has osteoporosis in the uncommon side effects list",
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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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173,458,789 | false | 12 | null | 6,494,974 | null | false | [] | null | 10,060 | {
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"__typename": "QuestionComment",
"comment": "dizziness is also a common side effect of alendronic acid, i would say this can increase the patient's risk of falls too..?",
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"comment": "diazepam dose not too high for an elderly lady?",
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"comment": "6g of paracetamol a day is a bit more overkill tbh",
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"comment": "am i just being stupid or is there not a risk with amlodipine? ",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "1. Ramipril is an angiotensin-converting enzyme inhibitor (ACEi) used to treat hypertension and heart failure. Antihypertensive medications such as ACEi and diuretics (i.e Furosemide) increase the risk of postural hypotension and therefore falls. This patient has a significant postural drop in their blood pressure (>20mmHg systolic) and this may have contributed to their fall. Mirtazapine also lists postural hypotension as a common side effect. Diazepam is a benzodiazepine used to treat muscle spasms and anxiety. Diazepam has sedative effects and may impair balance, increasing the risk of falls. \n\n2. Paracetamol should be prescribed in 500mg-1g doses 4-6 times per day with a maximum daily dose of 4g. This patient has been prescribed 6g daily, exceeding the maximum dose and therefore putting this patient at risk of paracetamol toxicity.",
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"comment": "apparently atorvastatin and allopurinol shouldn't be co prescribed too according to the BNF?",
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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).",
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173,458,791 | false | 14 | null | 6,494,974 | null | false | [] | null | 10,063 | {
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{
"__typename": "QuestionComment",
"comment": "Patient borderline hypokalaemic. More likely salbutamol than the rare s/e of omeprazole causing Hyponatremia",
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"comment": "Rare side effect of omeprazole and it doesn't appear in appendix 1 would this be in the exam?",
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"comment": "Did somebody else think that the frequency of salbutamol (QDS) is the dosing mistake? ",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "1. This patient is hyponatraemic. The three medications she is taking that are likely contributing to her hyponatremia are her omeprazole, carbamazepine and sertraline. It is thought that PPIs cause hyponatremia due to SIADH/salt-losing nephropathy due to acute interstitial nephritis however the mechanism is not fully understood. SSRIs cause hyponatremia due to SIADH, they inhibit the reuptake of noradrenaline which in turn stimulates ADH release. Finally, carbamazepine also causes hyponatremia due to SIADH. It does this via increasing ADH secretion, increasing sensitivity of the renal tubules to ADH activity and increasing aquaporin 2 channel expression.\n2. This patient would be taking 8g of carbamazepine daily, the maximum daily dose of carbamazepine is 2g.",
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"question": "Case presentation: A 33-year-old female attends the emergency department. She is complaining of feeling nauseous and has vomited 3 times. She also has a headache.\n\n\n\n\n **PH** Depression, seizures, gastro-oesophageal reflux disease, Raynaud's syndrome, asthma, allergic rhinitis\n\n\n **DH** Her current medications are listed (below). Weight 53kg.\n\n\n **On Examination**\n\n\n * GCS 15/15\n * Neurological examination: grossly intact\n * HS 1 + 2 + 0\n * Chest clear\n * Abdomen soft and non tender\n\n\n **Investigation**\n\n\nBloods:\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|128 mmol/L|135 - 145|\n|Potassium|3.9 mmol/L|3.5 - 5.3|\n|Creatinine|67 µmol/L|60 - 120|\n|eGFR|90 mL/min/1.73m<sup>2</sup>|> 60|\n\n\nCT head - no abnormalities detected\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of her abnormal blood results (mark them with a tick in column A)\n\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,458,792 | false | 15 | null | 6,494,974 | null | false | [] | null | 10,065 | {
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"__typename": "QuestionChoice",
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"explanation": "Acetylcysteine is used in the treatment of paracetamol poisoning. However, it is used; when a plasma paracetamol concentration is within the treatment threshold, where patients present later than 8 hours and have taken over 150mg/kg of paracetamol or where patients are visibly jaundiced.",
"id": "50088",
"label": "c",
"name": "Acetylcysteine IV",
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"explanation": "Haemodialysis is the treatment in severe salicylate poisoning. It would not be appropriate here.",
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"name": "Haemodialysis",
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"__typename": "QuestionChoice",
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"explanation": "It may be appropriate to give a patient with a paracetamol overdose a resuscitation fluid bolus where they vital signs are deranged, however, the patient in this case is currently stable.",
"id": "50090",
"label": "e",
"name": "500mL NaCl 0.9% in 10 minutes",
"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "Diazepam is used in patients who have taken an overdose of stimulant drugs or antipsychotics.",
"id": "50089",
"label": "d",
"name": "Diazepam 10mg PO (Oral)",
"picture": null,
"votes": 4
},
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has taken a paracetamol overdose and presented to A&E in under 1 hour, Activated charcoal should therefore be considered as the initial management of this patient.",
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"label": "a",
"name": "Activated Charcoal 50g PO (Oral)",
"picture": null,
"votes": 4257
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"__typename": "QuestionComment",
"comment": "bnf poisoning treatment summary - Although the benefit of gastric decontamination is uncertain, charcoal, activated should be considered if the patient presents within 1 hour of ingesting paracetamol in excess of 150 mg/kg.",
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"comment": "He has ingested 120 mg/kg, therefore he does not reach that threshold",
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"explanation": "#### Mechanism of Action\n\nParacetamol increases the pain threshold by inhibiting cyclooxygenase 1 and 2 (COX-1 and COX-2) which are involved in prostaglandin (PG) synthesis. Prostaglandins are responsible for nociception, so if prostaglandin is not synthesised, less nociception will occur. Paracetamol reduces fever by directly acting on heat-regulating centres in the brain, leading to peripheral vasodilation and sweating.\n\n#### Indications\n\n- Pain\n- Pyrexia\n\n#### Side Effects\n\n- Hypotension\n- Hypersensitivity reaction\n- Thrombocytopenia\n- Fulminant hepatic failure (in overdose)\n\n#### Cautions/Contra-indications\n\nGive 1g every four hours, up to a maximum of 4g in a day. Patients under 50kg are at increased risk of toxicity, so the dose must be lowered based on body weight.",
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"question": "Case Presentation: A 29-year-old man is brought to A&E after taking an overdose of paracetamol 20 minutes ago. He has ingested 18 tablets (9g) of paracetamol. **PH** Depression **DH** Citalopram 40mg Oral once daily, NKDA\n\n\n**On examination**\nThe patient looks well, not visibly jaundiced.\n\nBP 116/86, HR90, RR 16, Temperature 36.5°C\n\nWeight 75kg\n\n**Investigations**\n\nBlood to be taken 4hr after ingestion\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,793 | false | 16 | null | 6,494,974 | null | false | [] | null | 10,069 | {
"__typename": "QuestionSBA",
"choices": [
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"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",
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"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",
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"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.",
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"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",
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"name": "Stop his apixaban and continue to monitor",
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"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",
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"__typename": "QuestionComment",
"comment": "does anyone know if there is a tx summary or page on transfusion thresholds or bleeding?",
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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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173,458,794 | false | 17 | null | 6,494,974 | null | false | [] | null | 10,068 | {
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"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",
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"__typename": "QuestionChoice",
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"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",
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"explanation": "Whilst it is correct to prescribe an oral aminosalicylate, this dosage of sulfasalazine is for inducing remission NOT maintaining it.",
"id": "50104",
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},
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"__typename": "QuestionChoice",
"answer": true,
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"id": "50101",
"label": "a",
"name": "Prescribe sulfasalazine 500mg PO QDS",
"picture": null,
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"explanation": "This patient is clinically well, there is no need to readmit him.",
"id": "50103",
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"name": "Admit to hospital for a course of IV prednisolone",
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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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"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.",
"sbaAnswer": [
"a"
],
"totalVotes": 3300,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,795 | false | 18 | null | 6,494,974 | null | false | [] | null | 10,067 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has atrial fibrillation and a CHA₂DS₂-VASc of 5. (Age=2, TIA=2, treated hypertension = 1. 2+2+1=5.) Anticoagulation should therefore be initiated. Direct oral anticoagulants such as apixaban are the first-line medications used.",
"id": "50096",
"label": "a",
"name": "Start Apixaban 5mg Oral",
"picture": null,
"votes": 3003
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF). Warfarin was historically first line for anticoagulation in patients with AF although DOACs are now preferred as they have a lower bleeding risk and do not require regular monitoring.",
"id": "50098",
"label": "c",
"name": "Start Warfarin 5mg OD Oral and book follow-up in INR clinic",
"picture": null,
"votes": 209
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF) . Flecainide is a treatment option in paroxysmal atrial fibrillation as a ‘pill in pocket’ initiated by. This would not be appropriate here as it is a specialist treatment, this patient has a normal heart rate and there is no suggestion that their AF is paroxysmal.",
"id": "50100",
"label": "e",
"name": "Start Flecainide 50mg OD Oral",
"picture": null,
"votes": 284
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However, all of this patient's vital signs are stable.",
"id": "50097",
"label": "b",
"name": "Start DC Cardioversion",
"picture": null,
"votes": 159
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has atrial fibrillation (AF). Although clopidogrel is used in the management of patients after a TIA, where patients have AF, anticoagulation with DOACs is more appropriate than antiplatelet treatment as they have a greater risk of clot formation.",
"id": "50099",
"label": "d",
"name": "Start Clopidogrel 75mg OD Oral",
"picture": null,
"votes": 638
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "I thought you wait 2 weeks after a stroke to start a DOAC?",
"createdAt": 1706013728,
"dislikes": 0,
"id": "39641",
"isLikedByMe": 0,
"likes": 3,
"parentId": null,
"questionId": 10067,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Yes for stroke but this question is for TIA",
"createdAt": 1706281920,
"dislikes": 0,
"id": "39900",
"isLikedByMe": 0,
"likes": 4,
"parentId": 39641,
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"displayName": "Acute Ketone",
"id": 1306
}
}
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"user": {
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"accessLevel": "subscriber",
"displayName": "Zygomatic Hallux",
"id": 37217
}
}
],
"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",
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"demo": null,
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"id": "3599",
"name": "Anticoagulation in a new diagnosis of Atrial Fibrillation",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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"question": "Case Presentation: A 76-year-old man is admitted to the stroke ward following a TIA. **PH** TIA, Hyperlipidaemia, Gout **DH** Atorvastatin 20mg oral OD, Ramipril 5mg oral OD, Allopurinol 100mg oral OD. NKDA\n\n\n\n**On examination**\n\n* Irregularly irregular radial pulse and central pulse.\n* HS S1+S2\n* Chest clear on auscultation.\n* BP 130/80, HR 88, Temperature 37.1°C, O2 98% on room air\n\n**Investigations**\n\n - ECG: Irregularly irregular rhythm, no p waves\n - Transthoracic echocardiogram: normal\n - CT head normal\n - FBC,U&Es, LFTs and clotting studies are all NAD.\n\nQuestion: Select the most appropriate initial management at this stage, given the results of the investigations.",
"sbaAnswer": [
"a"
],
"totalVotes": 4293,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,796 | false | 19 | null | 6,494,974 | null | false | [] | null | 10,066 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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.",
"id": "50092",
"label": "b",
"name": "Benzylpenicillin 600mg IM",
"picture": null,
"votes": 582
},
{
"__typename": "QuestionChoice",
"answer": false,
"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
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "IV Amoxicillin is the treatment for meningitis caused by listeria. This patient has suspected meningitis with meningococcal septicaemia.",
"id": "50093",
"label": "c",
"name": "Amoxicillin 650mg IV",
"picture": null,
"votes": 24
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Phenoxymethylpenicillin is the chosen antibiotic to treat tonsillitis, oral infections and otitis media. This patient has suspected meningitis with meningococcal septicaemia.",
"id": "50095",
"label": "e",
"name": "Phenoxymethylpenicillin 125mg PO (Oral)",
"picture": null,
"votes": 18
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has suspected meningitis with meningococcal septicaemia. IV Cefotaxime or Ceftriaxone would be the most appropriate initial treatment in a hospital setting.",
"id": "50091",
"label": "a",
"name": "Cefotaxime 650mg IV",
"picture": null,
"votes": 2673
}
],
"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": "3598",
"name": "Suspected Meningitis Management",
"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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"conceptId": 3598,
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"dislikes": 2,
"explanation": null,
"highlights": [],
"id": "10066",
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"likes": 1,
"multiAnswer": null,
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 3301,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,797 | false | 20 | null | 6,494,974 | null | false | [] | null | 10,073 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Mood changes are not a recognised side effect of carbimazole treatment",
"id": "50127",
"label": "b",
"name": "To report any changes to mood",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Smoking can potentially reduce the efficacy of hyperthyroidism treatment however this isn't the most important thing to tell her out of the options provided.",
"id": "50128",
"label": "c",
"name": "To stop smoking",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no recognised interaction between sertraline and carbimazole",
"id": "50130",
"label": "e",
"name": "To stop taking her sertraline",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Treatment with carbimazole can cause bone marrow suppression. This is very serious side effect of carbimazole and needs to be mentioned when counselling on the drug. Any signs of infection, especially a sore throat should be reported immediately. After this, a full blood count should be taken. If this full blood count shows neutropenia then carbimazole should be stopped immediately.",
"id": "50126",
"label": "a",
"name": "To report having a sore throat",
"picture": null,
"votes": 4146
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alcohol can still be consumed whilst taking carbimazole. This patient however is above the recommended weekly limit so should look to reduce her alcohol consumption if possible.",
"id": "50129",
"label": "d",
"name": "To stop drinking alcohol",
"picture": null,
"votes": 17
}
],
"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": "3605",
"name": "Carbimazole treatment increases the risk of agranulocytosis",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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},
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"psaSectionId": 4,
"qaAnswer": null,
"question": "Case Presentation: A 38-year-old woman attends a follow up appointment at her GP for the results of her blood tests.\n\n\n\n\n **PMH** Depression, Asthma\n\n\n **DH** Salbutamol 200 micrograms INH PRN, Sertraline 50mg PO OD. NKDA\n\n\n **SH** Active smoker, smoking 10 cigarettes a day (5 pack year history). Drinks 20-30 units of alcohol a week.\n\n\n **Investigations**\n\n\n||||\n|---------------------------|:-------:|------------------------------|\n|Thyroid Stimulating Hormone|<0.1 mU/L|0.3 - 4.2|\n|Free T4|44 pmol/L|9 - 25|\n|Free T3|18 pmol/L|3.1 - 6.8|\n\n\nBased on her blood results she is diagnosed with hyperthyroidism. It is decided that she will be started on carbimazole 15mg PO OD.\n\n\nQuestion: Select the most appropriate piece of information that should be relayed to this patient prior to starting carbimazole",
"sbaAnswer": [
"a"
],
"totalVotes": 4187,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,798 | false | 21 | null | 6,494,974 | null | false | [] | null | 10,071 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"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",
"label": "d",
"name": "Blood glucose should be checked after each meal with a finger prick",
"picture": null,
"votes": 585
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insulin pens should be kept in the fridge. The low temperatures of a freezer may damage the insulin.",
"id": "50120",
"label": "e",
"name": "Insulin pens should be kept in the freezer",
"picture": null,
"votes": 33
},
{
"__typename": "QuestionChoice",
"answer": false,
"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,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"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,
"votes": 2634
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A side effect of insulin is weight gain, not weight loss.",
"id": "50118",
"label": "c",
"name": "Insulin may lead to weight loss",
"picture": null,
"votes": 20
}
],
"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": "3603",
"name": "Insulin and Hypoglycaemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3603,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10071",
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"multiAnswer": null,
"pictures": [],
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"psaSectionId": 4,
"qaAnswer": null,
"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.",
"sbaAnswer": [
"a"
],
"totalVotes": 3275,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,799 | false | 22 | null | 6,494,974 | 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. 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": 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. 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": 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",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "2657",
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"demo": null,
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"id": "3602",
"name": "Topical Corticosteroids",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
"totalCards": null,
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 3285,
"typeId": 1,
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173,458,800 | false | 23 | null | 6,494,974 | null | false | [] | null | 10,074 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "A penicillin allergy has no cross-sensitivity with penicillin based medications, it does however have cross-sensitivity with other non steroidal anti-inflammatories and aspirin.",
"id": "50133",
"label": "c",
"name": "She must not take ibuprofen if she has an allergy to amoxicillin",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Gastrointestinal discomfort is a very common side effect of ibuprofen use, especially with long term use. Ibuprofen inhibits the cyclo-oxygenase enzyme. This in turn increases the production of prostanoids such as prostaglandins. These prostaglandins then reduce the efficacy of the mucosal barrier within the stomach, making stomach ulcers more likely.",
"id": "50131",
"label": "a",
"name": "A long course of ibuprofen increases her risk of stomach ulcers",
"picture": null,
"votes": 4853
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen can increase a patient's cardiovascular risk however this is often the case in those with pre-existing cardiovascular disease who are taking ibuprofen long term.",
"id": "50132",
"label": "b",
"name": "A long course of ibuprofen will decrease her cardiovascular risk",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no requirement to check the function of the liver before taking ibuprofen.",
"id": "50134",
"label": "d",
"name": "She must have liver function tests before starting taking ibuprofen",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst constipation is a side effect of ibuprofen it is a rare/very rare side effect and therefore is unlikely to occur.",
"id": "50135",
"label": "e",
"name": "She is likely to experience constipation when taking ibuprofen",
"picture": null,
"votes": 126
}
],
"comments": [],
"concept": {
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Ibuprofen increases the risk of gastric ulcer formation",
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"topic": {
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"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
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"question": "Case presentation: A 54-year-old woman attends the GP with back pain. This back pain started after she bent over to pick up her phone off the floor yesterday. She has no neurological or sensory deficits. She is not incontinent.\n\n\n\n**PH**\nDepression\n\n**DH**\nSertraline 50mg\n\nOne of the medications offered includes ibuprofen, which is offered to the patient to relieve their back pain.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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173,458,801 | false | 24 | null | 6,494,974 | null | false | [] | null | 10,072 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vaginal dryness is a common symptom of menopause. HRT should help to prevent vaginal dryness. Topical preparations of oestrogen can be used to treat vaginal dryness where only local symptoms are menopause are bothersome.",
"id": "50124",
"label": "d",
"name": "HRT may cause vaginal dryness",
"picture": null,
"votes": 61
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cyclical HRT is a combination of oestrogen and a progestogen where the progestogen is taken in the second half of a 28day cycle. Patients taking this regimen will have a regular withdrawal bleed. The progestogen causes the uterus lining to build up. This is then shed when the progestogen is stopped. It is important to note that this is not a period as HRT does not restore/maintain ovulation.",
"id": "50123",
"label": "c",
"name": "HRT will stop your bleeding",
"picture": null,
"votes": 49
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Oral Progestogen should be taken later on in your cycle to induce a withdrawal bleed, this is usually from day 14-28.",
"id": "50122",
"label": "b",
"name": "Oral progestogen should be taken in the first 10 days of your cycle",
"picture": null,
"votes": 119
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "HRT is not a contraceptive and women under 40 should continue to use contraception until 2 years after their last period. Women over 50 should continue to use contraception for a year after their last period.",
"id": "50121",
"label": "a",
"name": "You should continue to use contraception for 2 years after your last period",
"picture": null,
"votes": 820
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "HRT patches should be applied below the waistline, usually on the buttock or lower abdomen.",
"id": "50125",
"label": "e",
"name": "HRT transdermal patches should be applied above the waistline",
"picture": null,
"votes": 114
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "# Summary \n \n \nHormone Replacement Therapy (HRT) is a treatment strategy used to alleviate menopausal symptoms by replacing diminishing hormones. It typically involves small doses of oestrogen and progestogen (if the woman has a uterus) to reduce endometrial cancer risk. HRT may be administered systemically or vaginally and can help manage symptoms such as flushing, insomnia, headaches, vaginal atrophy, and dryness. However, it may also have side effects including breast tenderness, leg cramps, bloating, nausea, and headaches. Key investigations involve assessing the history and physical examination of the patient to decide the need for HRT. Management strategies include careful dose regulation and monitoring for side effects.\n \n \n# Definition \n \n \nHormone replacement therapy (HRT) is a treatment to relieve symptoms of menopause by replacing hormones that decrease as a woman approaches the menopause. It typically involves small doses of oestrogen combined with a progestogen if a woman has a uterus to reduce the risk of endometrial cancer.\n \n \n \n# Indications \n \n \n - Symptomatic relief of vasomotor symptoms such as flushing, insomnia, headaches, vaginal atrophy and dryness\n - Decreases the risk of osteoporosis and colorectal cancer\n - In premature ovarian insufficiency, HRT should be continued until the age of 50. This is to help prevent the development of osteoporosis\n \n \n# Contraindications\n \n \n - Undiagnosed vaginal bleeding\n - Pregnancy\n - Breastfeeding\n - Oestrogen receptor-positive breast cancer\n - Acute liver disease\n - Uncontrolled hypertension\n - History of breast cancer or venous thromboembolism (VTE)\n - Recent stroke, myocardial infarction or angina\n\n\n# Types\n\n\nHRT can be given systemically, either via oral tablets, transdermal patches or gels, or can be given vaginally for urogenital atrophy, in the form of tablets, creams, pessaries or vaginal rings. Transdermal is the preferred route if the woman is at risk of VTE.\n\n\nHormones that can be given as part of HRT are:\n\n\n - **Oestrogens:** oestradiol, estrone and conjugated oestrogen are generally used.\n - **Progestogens:** Medroxyprogesterone, norethisterone, levonorgestrel and drospirenone are typically used. A levonorgestrel-releasing intrauterine system (e.g. Mirena coil) may be used as part of the progestogen component of HRT, so the woman may just take oral oestrogen and have endometrial protection via the intrauterine system\n - **Tibolone:** this is a synthetic compound containing oestrogen, progestogen and androgens.\n\n\nAll women require a combination of oestrogen and progesterone as part of their HRT, unless they have had a hysterectomy, in which case oestrogen-only is enough. This is due to risk of endometrial cancer if oestrogen is given alone. \n\nHRT can be given continuously (for postmenopausal women not having periods) or cyclically (for perimenopausal women still having some periods). Cyclical can include:\n\n- Monthly: Oestrogen every day of the month + progesterone for the last 14 days \n- Every three months: Oestrogen every day for 3 months + progesterone for the last 14 days\n\n\n# Side Effects\n\n\n - Oestrogen: breast tenderness, leg cramps, bloating, nausea, headaches\n - Progestogen: premenstrual syndrome-like symptoms, mood swings, breast tenderness, backache, depression, pelvic pain, fluid retention, weight gain\n - Cholestatic jaundice\n - Increased risk of breast cancer, endometrial cancer, VTE, stroke and ischaemic heart disease\n\n \n# NICE Guidelines\n\n[CLick here for NICE guidelines on HRT](https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt/)\n\n# References\n\n\n[Primary Care Women's Health Forum](https://pcwhf.co.uk/resources/hrt-types-doses-and-regimens/#)\n\n[Hickey & Davison 2012, The BMJ](https://www.bmj.com/content/344/bmj.e763.long)\n\n[NHS Website](https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/types-of-hormone-replacement-therapy-hrt/)",
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"id": "3604",
"name": "Hormone Replacement Therapy",
"status": null,
"topic": {
"__typename": "Topic",
"id": "76",
"name": "Obstetrics and Gynaecology",
"typeId": 5
},
"topicId": 76,
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"question": "Case presentation: A 44-year-old woman attends the GP with mood swings, hot flushes and an irregular menstrual cycle. She is having a menstrual bleed for around 4 days every 30-35 days. \n\n\n**PH**\nAsthma\n\n**DH**\nBeclometasone inhaler\n\nSalbutamol inhaler\n\nCombined Cyclical Hormone Replacement Therapy (HRT) in the form of transdermal oestrogen patches and an oral progestogen are offered to the patient.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 1163,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,802 | false | 25 | null | 6,494,974 | null | false | [] | null | 10,075 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Renal function tests are not required before starting sertraline.",
"id": "50138",
"label": "c",
"name": "He will need renal function tests before starting sertraline",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "The use of antidepressants such as sertraline have been linked to suicidal thoughts and behaviour. This predominantly occurs near the beginning of treatment and should be monitored for.",
"id": "50136",
"label": "a",
"name": "His mood may worsen for a few weeks after starting sertraline",
"picture": null,
"votes": 1140
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Liver function tests are not required before starting sertraline.",
"id": "50140",
"label": "e",
"name": "He will need liver function tests before starting sertraline",
"picture": null,
"votes": 10
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no listed interaction between sertraline and omeprazole. The ibuprofen he is taking does however interact with sertraline to increase the risk of bleeding.",
"id": "50137",
"label": "b",
"name": "He will need to stop taking his omeprazole due to it increasing the risk of bleeding when taken with sertraline",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Periorbital oedema is an uncommon side effect of sertraline, therefore it is not very likely to occur.",
"id": "50139",
"label": "d",
"name": "It is very likely that he will experience periorbital swelling after starting sertraline",
"picture": null,
"votes": 0
}
],
"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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"id": "2657",
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"chapterId": 2657,
"demo": null,
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"id": "3607",
"name": "Sertraline (SSRIs) increase the risk of a worsened mental state shortly after initiating treatment",
"status": null,
"topic": {
"__typename": "Topic",
"id": "90",
"name": "Psychiatry",
"typeId": 5
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"topicId": 90,
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"question": "Case presentation: A 26-year-old man attends his GP with low mood. This has persisted for 6 months. He has lost interest in his hobbies, has difficulty sleeping, has low energy levels and a low appetite. He has no active plans to harm himself or others although he does state 'sometimes I wish I wouldn't wake up'. He has no periods of heightened mood or psychotic symptoms. \n\n\n\n**PH**\nAnkylosing spondylitis\n\n**DH**\nIbuprofen 600mg QDS, omeprazole 20mg OD\n\nOne of the medications offered to treat his depression includes a sertraline which is offered to the patient to help treat his low moods.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
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"typeId": 1,
"userPoint": null
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173,458,803 | false | 26 | null | 6,494,974 | null | false | [] | null | 10,079 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin does not commonly cause dizziness.",
"id": "50157",
"label": "b",
"name": "Metformin 500mg PO BD",
"picture": null,
"votes": 152
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cholecalciferol does not commonly cause dizziness.",
"id": "50160",
"label": "e",
"name": "Cholecalciferol 800U OD",
"picture": null,
"votes": 75
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide does not commonly cause dizziness.",
"id": "50158",
"label": "c",
"name": "Gliclazide 80mg PO OD",
"picture": null,
"votes": 1996
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Chlorphenamine is a H1 antagonist used to treat hayfever. It can commonly cause drowsiness and dizziness; the latter is more likely when taken with oxybutynin as there is a higher risk of antimuscarinic side effects.",
"id": "50156",
"label": "a",
"name": "Chlorphenamine 10mg PO PRN",
"picture": null,
"votes": 1835
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause dizziness.",
"id": "50159",
"label": "d",
"name": "Paracetamol 1g PO BD",
"picture": null,
"votes": 12
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "would hypoglycaemia due to Gliclazide not be a concern?",
"createdAt": 1673963724,
"dislikes": 3,
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"replies": [
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"__typename": "QuestionComment",
"comment": "It is of concern, but the question specifically asks for an interaction with oxybutynin (at least it's stated like this right now)",
"createdAt": 1737993594,
"dislikes": 0,
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"id": 14043
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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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"id": "3611",
"name": "Interaction between oxybutynin and alendronic acid which increases the risk of dizziness.",
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"__typename": "Topic",
"id": "130",
"name": "Geriatrics",
"typeId": 5
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"topicId": 130,
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"question": "Case Presentation: A 82-year-old woman attends her GP. She has been feeling dizzy since being started on Oxybutynin for urge incontinence. Her regular medicines are listed (below).\n\n\n**PH** Osteoporosis, Type 2 Diabetes Mellitus, Hayfever Overactive Bladder\n\n**DH** Alendronic acid 10mg PO once weekly, Metformin 500mg PO BD, Gliclazide 80mg PO OD, Paracetamol 1g PO BD, Chlorphenamine 10mg PO PRN, Cholecalciferol 800U OD\n\n**On examination**\nBP 136/76mmHg, HR 71, RR 14, Weight 50kg\n\n**Investigation**\n\nNeurological examination is normal.\n\nQuestion: Select the prescription that is most likely to interact with the patient’s oxybutynin to cause dizziness.",
"sbaAnswer": [
"a"
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173,458,804 | false | 27 | null | 6,494,974 | null | false | [] | null | 10,077 | {
"__typename": "QuestionSBA",
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"__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": "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
},
{
"__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
},
{
"__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": "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
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "who's doing diazepam as a recreational drug ",
"createdAt": 1737909707,
"dislikes": 2,
"id": "61595",
"isLikedByMe": 0,
"likes": 5,
"parentId": null,
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"displayName": "Epidermis Benign",
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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 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?",
"sbaAnswer": [
"a"
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173,458,805 | false | 28 | null | 6,494,974 | null | false | [] | null | 10,081 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly interact with insulin to precipitate hypoglycaemia.",
"id": "50169",
"label": "d",
"name": "Paracetamol 1g PO QDS",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clarithromycin can increase the likelihood of hypoglycaemia when taken alongside insulin. Clarithromycin is a macrolide antibiotic that works by inhibiting bacterial protein synthesis by binding to the 50s ribosomal subunit.",
"id": "50166",
"label": "a",
"name": "Clarithromycin 500mg PO BD",
"picture": null,
"votes": 2533
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydromol cream does not commonly interact with insulin to precipitate hypoglycaemia.",
"id": "50168",
"label": "c",
"name": "Hydromol cream one application to affected area BD",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cetirizine does not commonly interact with insulin to precipitate hypoglycaemia.",
"id": "50170",
"label": "e",
"name": "Cetirizine 10mg PO OD",
"picture": null,
"votes": 45
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Sertraline does not commonly interact with insulin to precipitate hypoglycaemia.",
"id": "50167",
"label": "b",
"name": "Sertraline 50mg PO OD",
"picture": null,
"votes": 256
}
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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 16-year-old boy is brought to A&E by his mother as he is very drowsy. He is a known type 1 diabetic and treats this with insulin. He has recently had an ear infection, which is currently being treated with antibiotics by his GP. His regular medicines are listed (below).\n\n\n\n\n **PH** Type 1 diabetes mellitus, Depression, Eczema, Allergic Rhinitis\n\n\n **DH** Sertraline 50mg PO OD, Hydromol cream one application to affected area BD, Clarithromycin 500mg PO BD, Paracetamol 1g PO QDS, Cetirizine 10mg PO OD\n\n\nAllergic to penicillin - comes out in a rash\n\n\n **On examination**\nBP 109/68mmHg, HR 108, RR 24\n\n\nNeurological exam: Difficult to rouse the patient.\n\n\n **Investigation**\n\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.27|7.35 - 7.45|\n|PaO₂|10.0 kPa|11 - 15|\n|PaCO₂|3.4 kPa|4.6 - 6.4|\n|Bicarbonate|14 mmol/L|22 - 30|\n|Lactate|3 mmol/L|0.6 - 1.4|\n\n\nSerum BM 2.6 mmol/L (Fasting: 4.0 - 5.4 mmol/L, 2hrs post prandial: <7.8 mmol/L) , ketones 0.4mmol/L (<0.6 mmol/L)\n\n\nQuestion: Select the medication that is most likely to have interacted with this patient's diabetes medication to produce this clinical picture.",
"sbaAnswer": [
"a"
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173,458,806 | false | 29 | null | 6,494,974 | null | false | [] | null | 10,078 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlopidine is a calcium channel blocker used to treat hypertension. It is not known to interact with clopidogrel.",
"id": "50153",
"label": "c",
"name": "Amlodipine 10mg OD",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Aspirin is an anti-platelet used in conjunction with clopidogrel in dual antiplatelet therapy. Although used together there is an increased risk of bleeding, the benefits in preventing atherothrombotic events outweigh this risk when used short-term following high-risk TIAs.",
"id": "50155",
"label": "e",
"name": "Aspirin 75mg OD",
"picture": null,
"votes": 1200
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"__typename": "QuestionChoice",
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"explanation": "Esomeprazole is a proton pump inhibitor used to treat gastro-oesophageal reflux disease. Esomeprazole has been shown to decrease the efficacy of clopidogrel. Alternatives to esomeprazole such as H2 receptor antagonists should be considered.",
"id": "50151",
"label": "a",
"name": "Esomeprazole 40mg BD",
"picture": null,
"votes": 1516
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{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Simvastatin is used to treat hypercholesterolaemia and reduce the risk of ischaemic events. Simvastatin is not known to interact with clopidogrel.",
"id": "50154",
"label": "d",
"name": "Simvastatin 40mg OD",
"picture": null,
"votes": 110
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril is an angiotensin-converting enzyme inhibitor used to treat hypertension. It is not known to interact with clopidogrel.",
"id": "50152",
"label": "b",
"name": "Ramipril 5mg OD",
"picture": null,
"votes": 27
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The question should be phrased better. Should have said which drug reduces efficacy. ",
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"comment": "This is a good trick question. If you didn't read the stem and blindly searched in the BNF interaction checker, you wouldve probably picked aspirin.\n\nThe stem literally says he was discharged on dual antiplatelet therapy. The BNF treatment summary under \"Stroke\" also states that they should be considered for dual antiplatelet therapy of clopi and aspirin if there is low risk of bleeding.\n\nSo the next best option that has a potential interaction would be esomeprazole.\n",
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"comment": "I was in the midsts of writing a paragraph in rebuttal of your comment @Biopsy Cystic, only to conclude that you're actually right. Esomeprazole is the correct answer. ",
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"displayName": "Retake Prophylaxis ",
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"comment": "i read the stem and thought he was discharged on dual antiplatelet and then proceeded to have a reaction to clopi so needed alteration of the dual antiplatelet by the gp and was so confused, i dont think this question is super well worded",
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"__typename": "QuestionComment",
"comment": "Decreased efficacy is hardly an adverse reaction?",
"createdAt": 1709585101,
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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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"demo": null,
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"id": "3610",
"name": "Clopidogrel and Omeprazole",
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"typeId": 5
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"question": "Case Presentation: A 67-year-old man attends GP for follow-up after discharge from hospital following a crescendo TIA. His medications are listed on the right. He is discharged on dual antiplatelet therapy for 90 days. \n\n\n**PMH**\n\n* Stroke\n* Hypertension\n* Hyperlipidaemia\n* GORD\n\n**On examination**\n\n* Chest: Clear, RR 18\n* HS: S1 S2 + no added sounds\n\nQuestion: Which of the following medications should the GP consider stopping due to an adverse drug reaction to clopidogrel?",
"sbaAnswer": [
"a"
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173,458,807 | false | 30 | null | 6,494,974 | null | false | [] | null | 10,080 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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
},
{
"__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": "Tiotropium does not commonly interact with morphine.",
"id": "50164",
"label": "d",
"name": "Tiotropium 5micrograms INH OD",
"picture": null,
"votes": 104
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly interact with morphine.",
"id": "50165",
"label": "e",
"name": "Paracetamol 1g PO QDS",
"picture": null,
"votes": 79
},
{
"__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
}
],
"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",
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"name": "The use of trancylpromine alongside morphine increases the risk of opioid toxicity",
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"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
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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.",
"sbaAnswer": [
"a"
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"totalVotes": 3482,
"typeId": 1,
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173,458,808 | false | 31 | null | 6,494,974 | null | false | [] | null | 10,076 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin is a biguanide used to treat type 2 diabetes. It is not known to cause hyperkalaemia.",
"id": "50142",
"label": "b",
"name": "Metformin 500mg BD",
"picture": null,
"votes": 9
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has hyperkalaemia. Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i), a known adverse effect of ACE-is is hyperkalaemia.",
"id": "50141",
"label": "a",
"name": "Ramipril 5mg",
"picture": null,
"votes": 4671
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Co-amoxiclav is an antibiotic used to treat infections such as pneumonia. It is not known to cause hyperkalaemia.",
"id": "50144",
"label": "d",
"name": "Co-amoxiclav 250/125mg TDS",
"picture": null,
"votes": 31
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Gliclazide is a sulphonylurea used to treat type 2 diabetes. It is not known to cause hyperkalaemia.",
"id": "50143",
"label": "c",
"name": "Gliclazide 80mg OD",
"picture": null,
"votes": 26
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Omeprazole is a proton pump inhibitor used to treat gastro-oesophageal reflux disease (GORD). It is known to cause electrolyte imbalances such as hypokalaemia, hyponatraemia, hypocalcaemia and hypomagnesia due to increased renal losses. This patient has hyperkalaemia so this is unlikely to have been caused by omeprazole.",
"id": "50145",
"label": "e",
"name": "Omeprazole 40mg BD",
"picture": null,
"votes": 40
}
],
"comments": [],
"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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"id": "3608",
"name": "ACE-i - hyperkalaemia",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
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"topicId": 9,
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"question": "Case Presentation: A 56-year-old gentleman is admitted to the acute medical unit with pneumonia. Weight 90kg. His Medications are listed (below). \n\n\n\n\n **PMH**\n\n\n * Hypertension\n * GORD\n * Type II diabetes mellitus\n\n\n **On examination**\n\n\n * Chest: coarse crackles in left mid to lower zones.\n * HS S1 S2 + no added sounds\n * Abdo SNT\n * Temperature 38.1, BP 110/84, HR 96\n\n\n **Investigation**\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|136mmol/L|135 - 145|\n|Potassium|5.5 mmol/L|3.5 - 5.3|\n|Urea|5 mmol/L|2.5 - 7.8|\n|Creatinine|96 µmol/L|60 - 120|\n\n\nQuestion: Which medication is most likely to have contributed to his electrolyte abnormality?",
"sbaAnswer": [
"a"
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173,458,809 | false | 32 | null | 6,494,974 | null | false | [] | null | 10,086 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. A full blood count is part of routine monitoring due to the high risk of agranulocytosis when taking clozapine. A lipid profile is part of routine monitoring due to the increased risk of dyslipidaemia. A fasting blood glucose part of routine monitoring due to the increased risk of developing diabetes mellitus.",
"id": "50191",
"label": "a",
"name": "Full blood count, lipid profile, fasting blood glucose",
"picture": null,
"votes": 2644
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Renal function is not normally monitored in patients taking clozapine.",
"id": "50192",
"label": "b",
"name": "Full blood count, renal function, fasting blood glucose",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Hepatic function is not normally monitored in patients taking clozapine.",
"id": "50193",
"label": "c",
"name": "Full blood count, liver function tests, lipid profile",
"picture": null,
"votes": 83
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Renal and hepatic function tests are not normally monitored in patients taking clozapine.",
"id": "50195",
"label": "e",
"name": "Full blood count, renal function, liver function tests",
"picture": null,
"votes": 49
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Hepatic function is not normally monitored in patients taking clozapine. A chest x-ray is also not a part of the routine monitoring.",
"id": "50194",
"label": "d",
"name": "Full blood count, chest x-ray, liver function tests",
"picture": null,
"votes": 5
}
],
"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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"name": "Monitoring requirements before starting clozapine therapy",
"status": null,
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"id": "90",
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"typeId": 5
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"question": "Case Presentation: A 26-year-old known schizophrenic is seen in the outpatient psychiatric department.\n\n\n**Investigations**\n\nCardiovascular examination: Heart sounds I + II present, no added sounds.\n\nECG today: normal sinus rhythm\n\nProlactin today: 6 ng/mL (<20 ng/mL)\n\nHe is complaining of ongoing symptoms despite being treated with risperidone. He has also previously been treated with quetiapine which had to be switched due to lack of efficacy.\n\nIt is decided that he should be switched from risperidone to clozapine.\n\nQuestion: What monitoring is required if a patient is taking clozapine?",
"sbaAnswer": [
"a"
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173,458,810 | false | 33 | null | 6,494,974 | null | false | [] | null | 10,085 | {
"__typename": "QuestionSBA",
"choices": [
{
"__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": "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": 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": [
{
"__typename": "QuestionComment",
"comment": "Where is this mentioned in the BNF?\n",
"createdAt": 1705600679,
"dislikes": 0,
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"questionId": 10085,
"replies": [
{
"__typename": "QuestionComment",
"comment": "Under Hepatic impairment - \"Manufacturer advises monitor liver function periodically during early stages of therapy.\"",
"createdAt": 1705943067,
"dislikes": 0,
"id": "39587",
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"displayName": "Amnesia Yeast",
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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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"displayName": "Schistosomiasis",
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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.",
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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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173,458,811 | false | 34 | null | 6,494,974 | null | false | [] | null | 10,087 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than magnesium.",
"id": "50197",
"label": "b",
"name": "Serum magnesium",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited utility with respect to starting this drug.",
"id": "50198",
"label": "c",
"name": "Troponin",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While pancreatitis as a result of amiodarone use has been reported, this is a very rare side effect of amiodarone use. HPL also isn't a useful test as it can be raised for many reasons, it is also used for the **diagnosis** of acute pancreatitis, not for screening for acute pancreatitis.",
"id": "50199",
"label": "d",
"name": "Human pancreatic lipase",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Amiodarone contains iodine which in turn can commonly cause thyroid disorders. Both hypothyroidism and hyperthyroidism have been linked to amiodarone use. Amiodarone doesn't need to be withdrawn if it is essential and causes hypothyroidism, this can be treated with replacement therapy.",
"id": "50196",
"label": "a",
"name": "Thyroid function tests",
"picture": null,
"votes": 3967
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done.",
"id": "50200",
"label": "e",
"name": "Full blood count",
"picture": null,
"votes": 27
}
],
"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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"demo": null,
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"id": "3617",
"name": "TFTs should be measured before initiating treatment with amiodarone due to the increased risk of thyroid disorders",
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"question": "Case Presentation: A 64 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG Holter monitor. \n\n\n**PMH** myocardial infarction with 100% LAD occlusion, hypertension, hypercholesterolaemia, COPD\n\n**DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 10mg PO OD, amlodipine 5mg PO OD, salmeterol 50micrograms INH BD, tiotropium 5micrograms INH OD, atorvastatin 80mg PO OD. NKDA\n\n**Investigations**\n\n24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds\n\nIt is recommended to start amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an Implantable Cardioverter Defibrillator (ICD).\n\nQuestion: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.",
"sbaAnswer": [
"a"
],
"totalVotes": 4022,
"typeId": 1,
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173,458,812 | false | 35 | null | 6,494,974 | null | false | [] | null | 10,083 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Methotrexate increased the risk of blood dyscrasias, liver cirrhosis and blood dyscrasias. Bloods should be checked every 1-2 weeks until dosing stabilised and then every 2-3 months.",
"id": "50176",
"label": "a",
"name": "FBC, U&E and LFTs every 1-2 weeks until stabilised",
"picture": null,
"votes": 3598
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate is teratogenic and may also reduce fertility. It is therefore recommended that effective contraception is used during treatment and for 6 months afterwards for both men and women. Despite this, pregnancy prevention programmes are not routinely used in methotrexate therapy.",
"id": "50178",
"label": "c",
"name": "Pregnancy prevention programme",
"picture": null,
"votes": 150
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate is not known to cause any cardiac adverse reactions. An ECG is therefore not routine in the monitoring of methotrexate therapy.",
"id": "50179",
"label": "d",
"name": "ECG before starting",
"picture": null,
"votes": 10
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate level is not used in the monitoring of methotrexate therapy.",
"id": "50180",
"label": "e",
"name": "Methotrexate level every week",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Although Methotrexate is a folate antagonist, Haematinics (B12, folate, ferritin and intrinsic factor) are rarely monitored. Folic acid is instead taken weekly, to prevent deficiency.",
"id": "50177",
"label": "b",
"name": "Haematinics every 1-2 weeks until stabilised",
"picture": null,
"votes": 42
}
],
"comments": [],
"concept": {
"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "# Summary\n\nMethotrexate is one of several conventional disease-modifying anti-rheumatic drugs (DMARDs) used in a variety of autoimmune diseases. It is an inhibitor of dihydrofolate reductase, one of the key enzymes involved in purine and pyrimidine (and therefore DNA) synthesis. It is an immunosuppressive treatment that has several significant side effects, including hepatotoxicity, bone marrow suppression and pneumonitis. Folic acid should be co-prescribed with methotrexate as this reduces mucosal and gastrointestinal side effects (but should be taken on a different day as it reduces methotrexate's efficacy). Patients require regular monitoring with blood tests (full blood count, renal and liver function) and for women with the potential to become pregnant, highly effective contraception should be advised as methotrexate is teratogenic.\n\n# Definition\n\nMethotrexate is a conventional DMARD that inhibits DNA synthesis by inhibiting the enzyme dihydrofolate reductase. It has both immunosuppressive and cytotoxic effects and so is used in both autoimmune diseases such as rheumatoid arthritis, Crohn's disease and psoriasis, as well as in cancer treatment (e.g. as part of chemotherapy regimens for lymphoma).\n\n# Side Effects\n\n- Gastrointestinal upset (e.g. nausea, diarrhoea, abdominal pain)\n- Stomatitis and mucosal ulcers\n- Anorexia\n- Headache\n- Hair loss\n- Fatigue\n- Increased risk of infection; may reactivate latent infections\n- Teratogenicity \n- Myelosuppression with subsequent anaemia, leukopenia and thrombocytopenia\n- Hepatotoxicity including liver cirrhosis\n- Renal toxicity\n- Pulmonary toxicity especially pneumonitis; increased risk in rheumatoid arthritis\n- Photosensitivity reactions - may present with blistering or papular rashes and swelling of affected skin\n\n# Investigations\n\n**Baseline tests prior to starting methotrexate:**\n\n- Blood pressure\n- Weight and height\n- Pregnancy testing if appropriate \n- Full blood count (FBC)\n- U&Es for renal function (dose reduction may be needed; avoid methotrexate in severe impairment)\n- Liver function tests (avoid if baseline hepatic impairment)\n- Hepatitis B and C and HIV serology\n- Consider screening for tuberculosis and other lung disease e.g. with a chest X-ray\n\n**Monitoring whilst on treatment:**\n\n- FBC, U&Es and LFTs should be checked every 2 weeks until the dose of methotrexate is stable\n- They should then be checked monthly for 3 months, then at least every 3 months thereafter\n- More frequent monitoring may be required in patients at increased risk of toxicity\n\n**Ensure no contraindications are present, for example:**\n\n- Active infection - methotrexate should be paused during acute infections\n- Immunodeficiency syndromes\n- Ascites or significant pleural effusion (increases the risk of methotrexate accumulation unless drained)\n- Significant hepatic or renal impairment\n- Current peptic ulceration\n- Pregnancy or breast-feeding\n- Co-administration of another anti-folate medication e.g. co-trimoxazole\n\n**Consider cautions, such as:**\n\n- Excess alcohol intake (increases hepatotoxicity risk)\n- Renal impairment (may need to reduce dose)\n- Pre-existing haematological abnormalities e.g. anaemia, thrombocytopenia\n- Chronic respiratory disease\n- History of recurrent infections (e.g. urinary tract infections, chronic obstructive pulmonary disease exacerbations)\n- Frail or elderly patients (may require dose reduction)\n- Dehydration - may need to pause treatment e.g. if the patient develops diarrhoea or vomiting\n\n# Management\n\n- Methotrexate is usually taken as a weekly tablet, on the same day each week\n- Folic acid 5mg should be co-prescribed to be taken once weekly on a different day\n- Patients should receive the following vaccines:\n- Annual influenza vaccine\n- One-off pneumococcal vaccine (ideally prior to starting methotrexate)\n- Covid vaccination as per national guidelines\n- If aged 50+, the recombinant shingles vaccine (Shingrix, which is not a live vaccine)\n- Advise patients to avoid contact with people with chickenpox and shingles, and seek urgent medical advice if exposed\n- Advise patients that live vaccines (e.g. yellow fever) are contraindicated whilst on methotrexate\n- All patients should be under a specialist team (e.g. rheumatology), usually with a shared care agreement for prescribing and monitoring in primary care\n- A patient card should be provided with safety information and to show to other healthcare professionals\n- Medication interactions are important to be aware of, including:\n- NSAIDs increase the risk of methotrexate toxicity by decreasing renal excretion\n- Trimethoprim or co-trimoxazole may cause severe bone marrow suppression\n- Anti-epileptic medications may reduce effectiveness of methotrexate\n- Theophylline clearance may be reduced by methotrexate\n- Folic acid (may be included in multivitamin supplements) reduces effectiveness of methotrexate if taken together\n- Ensure women of childbearing age are advised of the risk of teratogenicity in pregnancy\n- Highly effective contraception is recommended\n- Methotrexate should be stopped at least 3-6 months before conception \n- Breastfeeding is also contraindicated\n- There is no strong evidence to suggest men need to stop methotrexate whilst trying to conceive, however the BNF suggests waiting 6 months after stopping methotrexate\n- Patients should be warned regarding the risk of photosensitivity reactions and advised to use sunscreen, protective clothing and avoid UV light exposure\n- If there are significant abnormalities in monitoring blood tests (e.g. thrombocytopenia, ALT or ALT > 100) or clinical signs or symptoms of complications (e.g. unexplained bruising suggestive of bone marrow suppression), hold methotrexate and arrange urgent specialist review \n- In cases of methotrexate toxicity, folinic acid (e.g. as calcium folinate) can be given to counteract methotrexate's folate-antagonist mechanism of action\n\n# NICE Guidelines\n\n[NICE CKS - DMARDs](https://cks.nice.org.uk/topics/dmards/)\n\n# References\n\n[BNF - Methotrexate](https://bnf.nice.org.uk/drugs/methotrexate/)\n\n[Specialist Pharmacy Service - Methotrexate monitoring](https://www.sps.nhs.uk/monitorings/methotrexate-monitoring/)",
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"question": "Case Presentation: A 36-year-old female patient attends the outpatient rheumatology clinic. He is due to commence treatment on methotrexate for rheumatoid arthritis. Weight 63kg.\n\n\n**PMH**\nDepression\n\n**DH**\nCerazette, 1 tablet daily\nCitalopram, 20mg OD\n\nQuestion: Which of the following is the most appropriate monitoring of a patient starting methotrexate?",
"sbaAnswer": [
"a"
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173,458,813 | false | 36 | null | 6,494,974 | null | false | [] | null | 10,082 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": true,
"explanation": "Statins work by inhibiting the enzyme HMG-CoA reductase, an enzyme that is responsible for the synthesis of cholesterol. By blocking this pathway, statins reduce the total level of circulating cholesterol and LDLs. A lipid profile at the start of treatment and in subsequent consultations is important in monitoring treatment response.",
"id": "50171",
"label": "a",
"name": "Lipid profile",
"picture": null,
"votes": 2787
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This should only be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin. It also would not be used to measure treatment response.",
"id": "50175",
"label": "e",
"name": "Creatinine kinase",
"picture": null,
"votes": 19
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Full blood count has no role in the monitoring of patients taking statins.",
"id": "50172",
"label": "b",
"name": "Full blood count",
"picture": null,
"votes": 6
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended to measure renal function prior to starting atorvastatin to assess for adverse effects. Monitoring renal function would not assess for treatment response.",
"id": "50174",
"label": "d",
"name": "Urea and electrolytes",
"picture": null,
"votes": 8
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "It is recommended that liver function should be measured prior to starting treatment and at 3 months and 12 months afterwards as atorvastatin is known to be hepatotoxic. However, this would be monitoring the treatment for an **adverse** effect, the question asks for the test that monitors treatment response.",
"id": "50173",
"label": "c",
"name": "Liver function test",
"picture": null,
"votes": 1026
}
],
"comments": [],
"concept": {
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Atorvastatin treatment response should be monitored by measuring the patient's full lipid profile",
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"question": "Case Presentation: A 56 year old gentleman attends a follow-up appointment at his GP. \n\n\n**PMH** hypertension\n\n**DH** ramipril 10mg PO OD, paracetamol 1g PO QDS\n\n**FH** Father died of heart attack at the age of 50. Mother died of an ischaemic stroke at the age of 64\n\n**SH** current smoker, 25-30 cigarettes a day but currently attending smoking cessation counselling.\n\n**Investigations**\n\nQ-risk score: 11%\n\nIt is decided that starting atorvastatin 20mg PO OD would help lower his risk of a cardiac event. A repeat consultation is booked in for 3 months later to assess treatment response.\n\nQuestion: Select the most appropriate option to monitor for treatment response at the next consultation.",
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"a"
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173,458,814 | false | 37 | null | 6,494,974 | null | false | [] | null | 10,084 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Furosemide has been shown to lead to some haematological adverse effects such as agranulocytosis and aplastic anaemia, however, a full blood count has little efficacy in demonstrating the beneficial symptomatic effects of furosemide.",
"id": "50185",
"label": "e",
"name": "Full Blood Count daily",
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"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "NT-proBNP is a hormone secreted by cardiomyocytes in response to stretching as a result of increased ventricular blood volume, it is therefore used diagnostically in cardiac failure. NT-proBNP is of little value in monitoring the symptomatic benefits of furosemide.",
"id": "50182",
"label": "b",
"name": "NT-ProBNP after 1 week",
"picture": null,
"votes": 64
},
{
"__typename": "QuestionChoice",
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"explanation": "Echocardiograms are used in the diagnostic and prognostic monitoring of cardiac failure, however, it has little value in monitoring the symptomatic benefits of furosemide.",
"id": "50183",
"label": "c",
"name": "Echocardiogram after 1 week",
"picture": null,
"votes": 42
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Furosemide is a loop diuretic used in the symptomatic treatment of cardiac failure. Daily weights are an effective way to measure the effectiveness of furosemide by quantifying fluid losses.",
"id": "50181",
"label": "a",
"name": "Daily weight measurements",
"picture": null,
"votes": 3643
},
{
"__typename": "QuestionChoice",
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"explanation": "Urea and Electrolytes (U&Es) should be monitored during furosemide therapy as furosemide can lead to electrolyte imbalance and AKI. However, U&Es have little efficacy in demonstrating the symptomatic benefits of Furosemide.",
"id": "50184",
"label": "d",
"name": "Urea and Electrolytes daily",
"picture": null,
"votes": 305
}
],
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"comment": "doesn't say in the bnf",
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"comment": "have you ever been to a ward like at all?",
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"explanation": "#### Monitoring\r\n\r\nThe BNF advises to monitor lung function (in patients with a history of obstructive airway disease).\r\n\r\n#### Overdoses\r\n\r\nOverdosages with beta-blockers may cause cardiac effects such as bradycardia, hypotension, syncope, conduction abnormalities, and heart failure. Bradycardia is the most common arrhythmia, but some beta-blockers may induce ventricular tachyarrhythmias secondary to prolongation of QT interval (e.g. sotalol) or QRS duration (e.g. propranolol).\r\nNon-cardiovascular effects include central nervous system effects (including drowsiness, confusion, convulsions, hallucinations, and in severe cases coma), respiratory depression, and bronchospasm.\r\n\r\nManagement\r\n - Airway protection \r\n - Activated charcoal within 1 hour\r\n - IV Fluids\r\n \r\nIV glucagon is the first-line management.\r\n \r\nFor symptomatic bradycardia, IV atropine may be used.\r\n",
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"question": "Case Presentation: A 72-year-old female patient is admitted to the acute medical ward with breathlessness. She is due to commence treatment on Furosemide for congestive cardiac failure. Weight 72kg.\n\n\n**PMH**\nMyocardial infarction\nType 2 diabetes mellitus\n\n**DH**\n\n* Atorvastatin, 40mg nightly\n* Clopidogrel, 75mg OD\n* Bisoprolol, 5mg OD\n* Ramipril, 7.5mg OD\n* Metformin, 500mg BD\n\nQuestion: Which of the following is the most appropriate monitoring of the beneficial effects of Furosemide therapy?",
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"a"
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173,458,815 | false | 38 | null | 6,494,974 | 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": "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": "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": "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 ",
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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",
"createdAt": 1737240796,
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"comment": "agree so much",
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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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173,458,816 | false | 39 | null | 6,494,974 | null | false | [] | null | 10,092 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Starting vancomycin would be correct however there is no clinical indication for stopping this patient's colecalciferol.",
"id": "50222",
"label": "b",
"name": "Suspend his colecalciferol and start vancomycin 125mg PO QDS",
"picture": null,
"votes": 479
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There is no clinical indication for stopping this patient's colecalciferol.",
"id": "50223",
"label": "c",
"name": "Suspend his colecalciferol",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This question requires you to know that PPIs increase the risk of clostridium difficile infection. In this case, the gentleman's omeprazole may be contributing to his c. difficile infection and therefore it should be stopped. The c. difficile infection should be treated, the first line treatment is vancomycin 125mg PO QDS (this patient is stable and therefore doesn't need a higher dose).",
"id": "50221",
"label": "a",
"name": "Suspend his omeprazole and start vancomycin PO QDS",
"picture": null,
"votes": 2077
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a c. difficile infection. Precipitants of said infection should be stopped (in this case the PPI) and antibiotics to treat the c. difficile should be given.",
"id": "50224",
"label": "d",
"name": "No change in treatment required",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Starting this patient on vancomycin would be the right thing to do however this is the wrong dose, and you would still also need to suspend the PPI he is taking due to it exacerbating c. difficile infections.",
"id": "50225",
"label": "e",
"name": "Start vancomycin 100mg PO QDS",
"picture": null,
"votes": 1198
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "The right answer should at least say the right dose and frequency. I was put off it because it said OD and I knew that the right dose was QDS",
"createdAt": 1675101372,
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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 79-year-old gentleman has been admitted to a general surgical ward. He has recently been treated for a pelvic collection with IV cefuroxime and metronidazole. He has finished his antibiotics and a repeat CT scan of his abdomen and pelvis shows that the collection has resolved. \n\n\nToday he is complaining of loose stools.\n\n**PMH** Depression, hypertension, hypercholesterolaemia, osteoporosis,\n\n**DH**\n\nOmeprazole 20mg PO BD, sertraline 50mg PO OD, atorvastatin 20mg PO OD, alendronic acid 10mg PO OD, colecalciferol 800 units PO OD\n\n**Investigations**\nObservations:\n\nHR 65 bpm, RR 12, blood pressure 123/67 mmHg, O2 saturations 96% on room air, temperature 37.4\n\nStool type - 7\n\nC. difficile toxin - positive\n\nQuestion: Select the most appropriate decision option based on this data",
"sbaAnswer": [
"a"
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173,458,817 | false | 40 | null | 6,494,974 | null | false | [] | null | 10,090 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst this patient is hypertensive, she is asymptomatic and systemically well. Hypertension with a systolic pressure of over 180mmHg and signs of end-organ damage such as retinal haemorrhage, papilloedema, new confusion, chest pain or signs of heart or kidney failure would require immediate admission as this would suggest malignant hypertension. It would therefore not be appropriate to admit this patient. The most important step at this stage would be stopping her COCP as this could be a cause of her hypertension. (!)",
"id": "50215",
"label": "e",
"name": "Admit to hospital",
"picture": null,
"votes": 153
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has a blood pressure of over 160mmHg systolic and the combined oral contraceptive pill should be stopped. Taking a 7-day break from the pill would not be appropriate here. Breaks from the combined oral contraceptive pill are used to induce withdrawal bleeds.",
"id": "50214",
"label": "d",
"name": "Take a 7-day break from microgynon",
"picture": null,
"votes": 117
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient is hypertensive. A systolic blood pressure of over 160mmHg (or >100mmHg diastolic) is a contraindication to COCP usage and it should be stopped.",
"id": "50211",
"label": "a",
"name": "Stop microgynon",
"picture": null,
"votes": 3199
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Microgynon and Dianette are both combined oral contraceptive pills. Dianette is used specifically to treat acne. This patient has a blood pressure of over 160mmHg systolic and so any COCP would be inappropriate.",
"id": "50212",
"label": "b",
"name": "Change microgynon to dianette",
"picture": null,
"votes": 373
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i) used to treat hypertension. Although an ACE-i would be the first choice of antihypertensive in a patient under the age of 55, stopping microgynon would be a more appropriate initial step. The patient's blood pressure may improve on cessation of the combined oral contraceptive pill.",
"id": "50213",
"label": "c",
"name": "Start ramipril",
"picture": null,
"votes": 158
}
],
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{
"__typename": "QuestionComment",
"comment": "where is the supporting info?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 26-year-old female patient takes the combined oral contraceptive pill (COCP) for endometriosis. She feels well in herself. \n\n\n**PMH**\nEndometriosis\n\n**DH**\nMicrogynon 30 one tablet daily\n\n**On Examination**\n\n* HR 84 bpm\n* Blood pressure 166/92 mm/Hg\n\nQuestion: Given the results of the above investigations, what is the most appropriate next step?",
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173,458,818 | false | 41 | null | 6,494,974 | null | false | [] | null | 10,089 | {
"__typename": "QuestionSBA",
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{
"__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,
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"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
},
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"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,
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},
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"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
}
],
"comments": [
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"__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",
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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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173,458,819 | false | 42 | null | 6,494,974 | null | false | [] | null | 10,093 | {
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{
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"explanation": "This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario.",
"id": "50228",
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"explanation": "This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario. A 250ml bolus is also not enough, this would typically be used in patients with pre-existing heart failure.",
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"name": "A fluid bolus of 250ml should be prescribed and given over <15 minutes",
"picture": null,
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"explanation": "This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes.",
"id": "50226",
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"name": "A fluid bolus of 500ml should be prescribed and given over <15 minutes",
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"explanation": "This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 45 minutes would take too long to give the fluid in this type of scenario.",
"id": "50230",
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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 gentleman is admitted to ED with generalised abdominal pain.\n\n\n\n\n **PMH** Nil\n\n\n **DH** Nil\n\n\n **Investigations**\n\n\nObservations: HR 112 bpm, RR 21, blood pressure 84/44 mmHg, temperature 38.4, O2 saturations 93% on RA\n\n\nAbdominal examination: tender to palpation in RUQ, bowel sounds present.\n\n\nBloods: CRP 211 mg/L (<5 mg/L), WCC 18.9 x 10<sup>9</sup>)L (3.6 – 11.0 x 10<sup>9</sup>)L)\n\n\nQuestion: Select the most appropriate decision option based on this data",
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173,458,820 | false | 43 | null | 6,494,974 | null | false | [] | null | 10,088 | {
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"explanation": "This patient's U&Es are normal. U&Es may become deranged in cases of digoxin toxicity (and as a consequence of ACE inhibitor therapy). In this case, there are no signs of digoxin toxicity and digoxin levels are below the therapeutic range. There is no indication to repeat the U&Es at this point.",
"id": "50205",
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"id": "50201",
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"explanation": "This patient's digoxin level is below the therapeutic range, they are therefore unlikely to be experiencing digoxin toxicity. An ECG may be helpful if toxicity is suspected to check for severe cardiac effects such as; sinoatrial and atrioventricular block,\npremature ventricular contractions (resulting in bigeminy or trigeminy) and PR prolongation and ST-segment depression.",
"id": "50204",
"label": "d",
"name": "ECG",
"picture": null,
"votes": 141
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient's digoxin level is below the therapeutic range, decreasing the patient's dose of digoxin would therefore be inappropriate.",
"id": "50202",
"label": "b",
"name": "Decrease the digoxin dose",
"picture": null,
"votes": 29
},
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"__typename": "QuestionChoice",
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"explanation": "This patient's digoxin level is below the therapeutic range, stopping digoxin in this patient would not be effective in controlling their atrial fibrillation.",
"id": "50203",
"label": "c",
"name": "Stop digoxin",
"picture": null,
"votes": 22
}
],
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 73-year-old gentleman takes Digoxin for atrial fibrillation. He attends the GP for a medication review. He is feeling well. His regular medicines are listed below. \n\n\n\n\n **PMH**\n\n\n * Atrial fibrillation\n * Previous MI\n * Peripheral vascular disease\n\n\n **DH**\n\n\n * Digoxin 250 micrograms OD\n * Ramipril 10mg OD\n * Amlodipine 5mg OD\n * Aspirin 75mg OD\n\n\n **On Examination**\n\n\n * HR 108 bpm\n * Blood pressure 126/84 mm/Hg\n\n\n **Investigations**\n\n\n * Digoxin level: 0.3nanograms/mL (Therapeutic range: 0.7-2nanograms/mL)\n\n\nBlood tests:\n\n\n\n||||\n|---------------------------|:-------:|--------------------|\n|Sodium|140 mmol/L|135 - 145|\n|Potassium|4.2 mmol/L|3.5 - 5.3|\n|Urea|6 mmol/L|2.5 - 7.8|\n|Creatinine|90 µmol/L|60 - 120|\n\n\n\nQuestion: Given the results of the above investigations, what is the most appropriate next step?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "500micrograms = 0.5mg\n\n0.5mg needed\n\n5mg in every 1ml\n\n0.5 / 5 = 0.1\n\n0.1mL of haloperidol solution should be delivered.",
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"question": "A 93-year-old man has acute hyperactive delirium. He has become aggressive towards nursing staff and attempts to calm him down have failed. The medical registrar decides to give a dose of 500micrograms of Haloperidol intramuscularly. The solution for injection of contains 5mg/ml of Haloperidol.\n\nHow many millilitres of the solution should be given?",
"sbaAnswer": null,
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173,458,822 | false | 45 | null | 6,494,974 | null | false | [] | null | 10,094 | {
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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": "I got 11 tablets because i thought that with the .5 tablet left after each regular dose you have to waste the other half as its a CD?",
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"comment": "if the breakthrough dose is 10mg, the daily dose must be six times more so 60mg (6 tablets). if shes taking 3 breakthrough doses thats another 3 tablets. 3+6=9 tablets.\n",
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"comment": "I assumed it meant the break through doses only as the 15 mg morphine was already part of her daily regimen. So I put 3",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "Since the hospital only has 10mg tablets, that means for her regular morphine dose, she requires 1.5 tablets each time. 1.5 x 4 = 6\n\nShe has had 3 doses of 10mg morphine as breakthrough pain which is 3 tablets. 6 + 3 = 9 tablets.",
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"question": "Case Presentation:\r\n\r\nA 75-year-old woman is admitted to the medical ward for palliative care. Her regular medicines are listed (below). Weight 60kg.\r\n\r\n**PH** Hypertension, Hypercholesterolaemia, Osteoarthritis, Iron deficiency anaemia\r\n\r\n**DH** Amlodipine 5mg PO OD, Morphine 15mg PO QDS\r\n\r\nShe is still complaining that she is in pain. She is being given 10mg morphine tablets as a way to manage her breakthrough pain.\r\n\r\nThroughout the day, the patient requires 3 breakthrough doses to control her pain.\r\n\r\nGiven that hospital only stocks 10mg tablets, how many morphine tablets will the patient have had by the end of the day?",
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"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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"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": "To calculate the patients weight: volume required/volume per hour= 1200/25= 48kg\n\nPatients require the replacement of 1mmol/kg of potassium each day.\n\n1x48=48mmol required\n\n",
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"question": "A 89-year-old patient requires maintenance fluids as she is Nil-by-mouth due to an unsafe swallow. She is prescribed 1200ml of 0.9% sodium chloride every 24 hours - calculated based on requirements of 25ml/kg/day.\n\nHow many mmol of potassium should she be given in 24 hours?",
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"comment": "i forgot to multiply my answer by 5 oops",
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"comment": "where does it say how many mg does the pt need in a day?\n",
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"comment": "you have to search for the dose of amoxicillin for community acquired pneumonia in the bnf",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "The patient requires a daily dose of 1.5g (1500mg) of amoxicillin (500mg to be taken 3 times a day).\n\nThey have been discharged with 250mg tablets. 1500/250 = 6 tablets needed per day.\n\nThe duration of treatment is 5 days. 5 x 6 = 30. 30 total tablets are therefore needed.",
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"question": " \n\nCase Presentation:\n\nA 64-year-old gentleman attends his GP complaining of a productive cough and shortness of breath. His regular medicines are listed (below). Weight kg.\n\n**PH** Osteoarthritis, Depression\n\n**DH** Ibuprofen 200mg PO QDS, Omeprazole 20mg PO OD, Sertraline 50mg PO OD\n\n**On examination**\nBP 134/74mmHg, HR 78, RR 16, patient is alert\n\nRespiratory exam: Crepitations heard in the left middle zone on auscultation\n\nThe GP decides that this is a community acquired pneumonia and prescribes the patient 250mg amoxicillin capsules to take at home.\n\nHow many amoxicillin tablets should the patient be discharged with for a duration of 5 days?",
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"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",
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"comment": "would it be wrong if i wrote sertraline 25mg in medicine option",
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"comment": "I think it would be wrong in the actual PSA as you can't cut tablets in half",
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"comment": "how can you dose 50mg tablets at 25mg per dose ",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis gentleman has 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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"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,
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"typeId": 4,
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} | MarksheetMark |
173,458,835 | false | 2 | null | 6,494,976 | null | false | [] | null | 10,105 | {
"__typename": "QuestionPrescription",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"explanation": "## Drug choice feedback\n\nThis patient is in acute anaphylaxis. The treatment for this is adrenaline (also known as epinephrine). As this patient is an adult the standard dose that he should be given is 500 micrograms IM in the anterolateral aspect of his thigh. There is a reduced dose of 300 micrograms for children aged 6-11 years, 150 micrograms for children aged 6 months-5years\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's anaphylaxis:\n\n- Adrenaline/Epinephrine 1 in 1000 (1 mg/mL) 500 micrograms IM every 5 minutes",
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"question": "Case Presentation: A 18-year-old gentleman is brought to the emergency department with a swollen face, widespread rash and difficulty breathing. His friend with him says that the symptoms randomly happened during a meal at a restaurant.\n\n\n## PH\nAsthma\n\n## DH\nSalbutamol 200 micrograms INH QDS. NKDA.\n\n## On examination\n\nAirway patent, patient is alert and orientated.\n\nTemperature 37.3°C, HR 128, RR 26, BP 101/653, O<sub>2</sub> 94% RA, GCS 15, Weight 60kg\n\nRespiratory exam: widespread wheeze heard on auscultation.\n\nCardiovascular exam: HS 1 + 2 + 0, his pulse feels weak.\n\nAbdominal exam: abdomen soft and non tender with no palpable organomegaly\n\nNeurological exam: grossly intact\n\nMultiple hives are seen over his abdomen and thorax when his top is removed.\n\n## Investigations\n\nFBC: Hb 139, WCC 4.6, Plts 255 x 10^9\n\nCRP 18\n\nU&Es: Na 140, K 4.2, Ur 4.9, Cr 54, eGFR >90mL/min/1.73m<sup>2</sup>\n\nCa2+ (adjusted): 2.3\n\nMg2+: 0.9\n\nPhosphate: 0.81\n\nLFTs: ALP 30, ALT 24, bilirubin 13\n\nECG - sinus tachycardia\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat this condition.",
"sbaAnswer": null,
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173,458,836 | false | 3 | null | 6,494,976 | null | false | [] | null | 10,104 | {
"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "why not fondaparinux?",
"createdAt": 1737391388,
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"__typename": "QuestionComment",
"comment": "it is an antithrombin, this patient needs LMWH or aspirin ",
"createdAt": 1738089187,
"dislikes": 0,
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"__typename": "QuestionComment",
"comment": "What's wrong with enoxaparin sodium 150 mg/mL injection with 40mg SC daily? ",
"createdAt": 1737819680,
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"__typename": "QuestionComment",
"comment": "Probably because in reality if you are trying to get 40mg from 100mg/ml you can give 0.4ml but if it's 150 its like 0.375 I think?",
"createdAt": 1737909040,
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"displayName": "Epidermis Benign",
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},
{
"__typename": "QuestionComment",
"comment": "i put stat as first dose is stat as bnf says: 40 mg for 1 dose, dose to be given 12 hours before surgery, then 40 mg every 24 hours. but got it wrong",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Prescribing VTE prophylaxis",
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"id": "13",
"name": "Neurosurgery",
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"explanation": "## Drug choice feedback\n\nThis patient requires a low molecular weight heparin as prophylactic treatment of venous thromboembolism prior to his surgery. The options available are tinzaparin, enoxaparin, bemiparin and dalteparin. They are often given at 6pm, this provides cover until the day of the surgery. DOACs such as rivaroxaban are now also licensed to be given as VTE prophylaxis **AFTER** (and so are incorrect answers for this question) specific procedures (such as knee and hip replacements) and these should be taken daily for 2 weeks. Similarly, Fondaparinux is not acceptable as per the BNF, which only provides information on prescribing it for VTE prophylaxis **post-surgery.**\n\n# Dose/Route/Frequency/Duration feedback\n\nThe following prescriptions are appropriate to provide prophylaxis against venous thromboembolism:\n\n- Enoxaparin 40mg subcutaneous OD\n- Tinzaparin 4500 units subcutaneous OD\n- Dalteparin 5000 units subcutaneous OD\n- Bemiparin 3500 units subcutaneous OD\n",
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"question": "Case Presentation: A 63-year-old gentleman is brought onto the orthopaedic ward for an elective total knee replacement of his right knee. \n\n\n## PH\nOsteoarthritis\n\n## DH\nIbuprofen 400mg PO QDS, lansoprazole 30mg PO OD. NKDA.\n\n## On examination\n\nTemperature 37.1°C, HR 68, RR 13, BP 131/75, O<sub>2</sub> 98% RA, GCS 15, Weight 90kg\n\n## Investigations\n\nNil\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to provide cover against venous thromboembolism. It is the day before his elective surgery.",
"sbaAnswer": null,
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173,458,837 | false | 4 | null | 6,494,976 | null | false | [] | null | 10,103 | {
"__typename": "QuestionPrescription",
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{
"__typename": "QuestionComment",
"comment": "what about docusate?",
"createdAt": 1738065460,
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"__typename": "QuestionComment",
"comment": "Its a softener ",
"createdAt": 1738095918,
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"displayName": "Intravenous Power",
"id": 32889
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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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"demo": null,
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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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"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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"__typename": "PrescriptionAnswer",
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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,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,458,838 | false | 5 | null | 6,494,976 | null | false | [] | null | 10,102 | {
"__typename": "QuestionPrescription",
"choices": [],
"comments": [
{
"__typename": "QuestionComment",
"comment": "where do i find information on group b strep and the antibiotic of choice on the BNF?\n",
"createdAt": 1708363661,
"dislikes": 0,
"id": "42096",
"isLikedByMe": 0,
"likes": 8,
"parentId": null,
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"replies": [
{
"__typename": "QuestionComment",
"comment": "you type 'group b streptococcal' on the bnf and it will come up as benzylpenicillin",
"createdAt": 1709829727,
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"concept": {
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "3631",
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"topic": {
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"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
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"explanation": "## Drug choice feedback\n\nThis patient has a group B streptococcus infection. Streptococcus agalactiae is the most common pathogen that belongs to the Group B streptococcus family. Treatment of Group B strep during labour is with IV benzylpenicillin, initially this should be a 3g IV infusion followed by 1.5g IV infusions every 4 hours until delivery.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe following prescription is appropriate to treat this patient's group B streptococcus infection:\n\n- Benzylpenicillin 3g IV once-off, and then 1.2g every 4 hours",
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"question": "Case Presentation: A 33-year-old 37 week pregnant woman attends the maternity ward as she has gone into labour.\n\n\n## PH\nNil.\n\n## DH\nNil. NKDA.\n\n## On examination\n\nPatient comfortable at rest. No evidence of any oedema or the face or peripheral areas.\n\nSymphysial-fundal height is 37cm, the position of the foetus is a longitudinal lie with cephalic palpation.\n\nTemperature 37.3°C, HR 88, RR 16, BP 126/78, O<sub>2</sub> 98% RA, GCS 15, Weight 85kg\n\n## Investigations\n\nFBC: Hb 124, WCC 4.8, Plts 253 x 10^9\n\nCRP 2\n\nU&Es: Na 141, K 4.3, Ur 5.0, Cr 64, eGFR >90mL/min/1.73m<sup>2</sup>\n\nCa2+ (adjusted): 2.4\n\nMg2+: 0.8\n\nPhosphate: 0.82\n\nLFTs: ALP 31, ALT 23, bilirubin 12\n\nTFTs: TSH 1.3, T4 11, T3 8\n\nMSU: Streptococcus agalactiae\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to give while she is in labour.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,458,839 | false | 6 | null | 6,494,976 | null | false | [] | null | 10,100 | {
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{
"__typename": "QuestionComment",
"comment": "on the bnf it says montelukast is for prophylaxis of asthma, not mentioned in treatment summaries ",
"createdAt": 1736874006,
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"displayName": "CT Kawasaki",
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"__typename": "QuestionComment",
"comment": "the guidelines have changed so if not controlled by moderate MART it says tiotropium?\n",
"createdAt": 1737241969,
"dislikes": 0,
"id": "60942",
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"__typename": "QuestionComment",
"comment": "this is what BNF says: If asthma is still uncontrolled in patients on a moderate-dose of ICS as maintenance with a LABA (either as a MART or a fixed-dose regimen), with or without a LTRA, consider the following options:\n\nIncreasing the ICS dose to a high-dose as maintenance (this should only be offered as part of a fixed-dose regimen with a short-acting beta2 agonist used as reliever therapy), or\nA trial of an additional drug, for example, a long-acting muscarinic receptor antagonist (such as tiotropium) or modified-release theophylline, or",
"createdAt": 1737242020,
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"__typename": "QuestionComment",
"comment": "https://www.asthmaandlung.org.uk/healthcare-professionals/adult-asthma/managing \n\nThis link provides a photo of the new NICE/ BTS/ SIGN guidelines. If not controlled on moderate MART, you can start a LTRA or LAMA as you mentioned",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"id": "3629",
"name": "Prescribing a LABA in an asthmatic patient",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
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"explanation": "## Drug choice feedback\n\nThis patient's asthma isn't controlled. She is already taking moderate-dose MART. The next step in her treatment would be trial of LAMA or a leukotriene receptor antagonist, in accordance with NICE guidelines. However, because the patient is keen to avoid additional inhalers, montelukast would be the most appropriate option.\n\n## Dose/Route/Frequency/Duration feedback\n\nThe options available to treat this patients uncontrolled asthma are as follows:\n\n- Montelukast 10mg PO OD",
"highlights": [],
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"question": "Case Presentation: A 23-year-old woman attends her GP to shortness of breath and wheeze. She experiences this intermittently, her symptoms are most likely to occur at night and after exercising. Her FeNO level is re-checked and it is not raised. She is keen to avoid using any more inhalers.\n\n\nShe has good inhaler technique and is taking her prescribed medications as recommended.\n\n## PMH\nAsthma\n\n## DH\nModerate-dose MART.\n\nNKDA.\n\n## On examination\n\nTemperature 36.6°C, HR 68, RR 16, BP 115/78, O<sub>2</sub> 98% RA, GCS 15, Weight 55kg\n\nA polyphonic wheeze is heard on auscultation of her chest, no other abnormalities found.\n\n## Investigations\n\nFEV1/FVC ratio: 56%. FeNO level and blood eosinophils are normal.\n\n## Prescribing Request\n\nWrite a prescription for one drug that is most appropriate to treat her asthma based on NICE guidelines.",
"sbaAnswer": null,
"totalVotes": null,
"typeId": 4,
"userPoint": null
} | MarksheetMark |
173,458,840 | false | 7 | null | 6,494,976 | null | false | [] | null | 10,111 | {
"__typename": "QuestionMultiA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": null,
"id": "50282",
"label": "g",
"name": "Gliclazide;80mg;PO;OD",
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"__typename": "QuestionChoice",
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"id": "50276",
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"id": "50279",
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"id": "50281",
"label": "f",
"name": "Fluticasone;200 micrograms;INH;BD",
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"id": "50277",
"label": "b",
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"id": "50280",
"label": "e",
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},
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"explanation": null,
"id": "50283",
"label": "h",
"name": "Fluoxetine;60mg;PO;OD",
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"comments": [
{
"__typename": "QuestionComment",
"comment": "\"Some studies suggest a small increased risk of cardiovascular malformations with the use of fluoxetine, and congenital malformations (particularly cardiovascular) with the use of paroxetine, however other studies do not support an association\" \"The available data regarding malformation risk for all SSRIs are conflicting and confounded, and a causal association between the use of SSRIs in pregnancy, and spontaneous miscarriage, preterm delivery, low birth weight, and adverse effects on infant neurodevelopment remains unconfirmed.\" literally does not say anywhere to stop fluoxetine on the BNF",
"createdAt": 1705163220,
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"comment": "What antidepressants can be used in pregnancy?",
"createdAt": 1737652991,
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"__typename": "QuestionComment",
"comment": "sertraline and citalopram ",
"createdAt": 1737847023,
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"id": "61549",
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"createdAt": 1738166181,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"name": "Lithium and isotretinoin are teratogenic medications and a dosing error in paracetamol",
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"__typename": "Topic",
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"typeId": 5
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"explanation": "1. Lithium and isotretinoin are teratogenic. Lithium is linked with an increased risk of Ebstein's anomaly occurring. Isotretinoin is linked with an increased risk of cardiovascular and ear malformations. Gliclazide should be stopped due to the increased risk of neonatal hypoglycaemia. The BNF advises that antihistamines should be avoided during pregnancy. NB: newer research now suggests that SSRIs including fluoxetine can be safely taken during pregnancy, however the pros and cons should be considered, and it should be given at the lowest effective dose.\n\n2. The dose of paracetamol should be 1g PO QDS in this patient, 1mg is an incorrect dose.",
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"question": "Case presentation: A 28-year-old woman is attends her GP complaining of nausea in the morning. \n\n\n**PH** Bipolar disorder, asthma, type 2 diabetes mellitus, acne, allergic rhinitis\n\n**DH** Her regular medicines are listed (below). Weight 108kg.\n\n**Investigation**\n\nUrinary beta hCG ++\n\nQuestion 1: Select the FOUR prescriptions that she will need to stop taking given her urinary beta hCG test results (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,458,841 | false | 8 | null | 6,494,976 | null | false | [] | null | 10,106 | {
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"comment": "where does it say in the BNF that methylphenidate causes cold peripheries?",
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"comment": "its under side effects as 'peripheral coldness' annoyingly",
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"comment": "methylphenidate 'coldness' is literally under rare S/E",
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"comment": "doesnt ramipril cause raynauds though\n",
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"comment": "Who on earth is giving this woman methylphenidate ",
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"explanation": "1. Both bisoprolol and methylphenidate can cause patient's to experience cold peripheries. Bisoprolol commonly causes cold peripheries as they reduce the amount of blood that is delivered to the fingers and toes.\n2. The maximum dose of ramipril that a patient can take is 10mg PO OD therefore this prescription contains a mistake.",
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"question": "Case presentation: A 78-year-old female is admitted to the cardiology ward. During her stay she has been complaining of cold peripheries.\n\n\n**PH** Congestive cardiac failure, type 2 diabetes mellitus, hypertension, oseteoarthritis hypercholesterolaemia, COPD, ADHD, depression\n\n**DH** Her current medications are listed (below). Weight 110kg.\n\n**On Examination**\n\nHR 88/min, BP 114/89mm Hg, RR 24, O2 sats 92% RA. HS I + II with no added heart sounds. Bilateral basal crepitations heard on auscultation of the lungs.\n\n**Investigation**\n\nCXR shows bilateral pleural effusions\n\nQuestion 1: Select the TWO prescriptions that are most likely to be the cause of her cold peripheries (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,458,842 | false | 9 | null | 6,494,976 | null | false | [] | null | 10,109 | {
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"label": "d",
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"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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"explanation": "1. ACE inhibitors, NSAIDs and thiazide like diuretics all increase the serum concentration of lithium. This is due to their effects on kidney function, a reduction in kidney function results in a reduced clearance of lithium. This in turn then leads to higher serum concentration of lithium.\n2. Bendroflumethiazide should be given as a 2.5mg tablet once daily in hypertensive patients, NOT 2.5g.",
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"question": "Case presentation: A 69-year-old gentleman attends his lithium clinic appointment \n\n\n\n\n **PH** Bipolar disorder, seizures, hypertension, depression, asthma, osteoarthritis\n\n\n **DH** His regular medicines are listed (below). Weight Xkg.\n\n\n **Investigation**\n\n\nLithium concentration 1.5 mEq/L (0.8-1.2 mEq/L)\n\n\nQuestion 1: Select the THREE prescriptions that are most likely to be interacting with his lithium to increase its serum concentration (mark them with a tick in column A)\n\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
"sbaAnswer": null,
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173,458,843 | false | 10 | null | 6,494,976 | null | false | [] | null | 10,107 | {
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"name": "The combined oral contraceptive pill, ramipril and metformin are all medications that need stopping before surgery and dosing error of a salbutamol inhaler",
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"id": "13",
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"explanation": "1. Ramipril, microgynon 30 and metformin should be held before surgery. COCPs should be held for 4 weeks prior to surgery due to the increased risk of thromboembolism. ACE inhibitors/angiotensin-II receptor antagonists should be omitted the day before surgery due to an increases risk of severe hypotension after induction of anaesthesia. Metformin can also be held before surgery if there is an increased risk of lactic acidosis occurring.\n\n2. The maximum dose of salbutamol per administration is 200 micrograms NOT milligrams.",
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"question": "Case presentation: A 42-year-old woman is admitted to the general surgical ward due to gallstones. It is decided that she should have an outpatient laparoscopic cholecystectomy.\n\n\n**PH** Depression, hypercholesterolaemia, hypertension, type 2 diabetes mellitus, asthma, chronic fatigue syndrome, allergic rhinitis\n\n**DH** Her current medicines are listed (below). Weight 118kg.\n\n**On Examination**\nHR 81/min, BP 112/80mm Hg, RR 14, O2 Sats 96% RA, temperature 37.1\n\nAbdomen soft, tender in RUQ. Bowel sounds present.\n\n**Investigation**\n\nUSS abdomen - thickened gallbladder wall and multiple gallstones within the gallbladder. No perforation.\n\nQuestion 1: Select the THREE prescriptions that are most likely to be stopped before her elective surgery (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,458,844 | false | 11 | null | 6,494,976 | null | false | [] | null | 10,110 | {
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"comment": "paracetamol 1g qds is right ?",
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"comment": "yes max 4g/d",
"createdAt": 1708170896,
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"name": "Taking 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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173,458,845 | false | 12 | null | 6,494,976 | null | false | [] | null | 10,112 | {
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"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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"question": "Case presentation: A 83-year-old gentleman attends his GP due to issues with his sleep.\n\n\n**PH** Atrial fibrillation, hypercholesterolaemia, COPD, gout, benign prostatic hyperplasia, hypertension, depression\n\n**DH** His regular medicines are listed (below). Weight 54kg.\n\nQuestion 1: Select the THREE prescriptions that are most likely to be a cause of his issues with sleeping (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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173,458,846 | false | 13 | null | 6,494,976 | null | false | [] | null | 10,108 | {
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"picture": null,
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"__typename": "QuestionComment",
"comment": "I swear PPI causes loose stools\n",
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"comment": "Isn't constipation a common side-effect for ibuprofen as well?\n",
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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. PPIs, ACE inhibitors, beta blockers and statins commonly cause constipation. Whilst other medications that this patient is on such as clopidogrel, tamsulosin and ibuprofen can cause constipation, these aren't listed as common/very common side effects unlike the omeprazole, ramipril, bisoprolol and atorvastatin.\n\n2. The normal dose for tamsulosin when treating benign prostatic hyperplasia is 400 micrograms. This patient is receiving 400 milligrams of tamsulosin which is much higher than the maximum dose he should be receiving.",
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"question": "Case presentation: A 72-year-old gentleman attends his GP complaining of constipation\n\n\n**PH** Benign prostatic hyperplasia, osteoarthritis, hypertension, prior myocardial infarction, hypercholesterolaemia, allergic rhinitis, gastro-oesophageal reflux disease,\n\n**DH** His current medicines are listed (below). Weight 81kg.\n\nQuestion 1: Select the FOUR prescriptions that are most likely to be contribute to his constipation (mark them with a tick in column A)\n\nQuestion 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).",
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173,458,847 | false | 14 | null | 6,494,976 | null | false | [] | null | 10,113 | {
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"explanation": "This patient has COPD that isn't controlled on his current medication. This isn't an acute exacerbation as his observations are stable and his bloods are unremarkable. He has no signs of steroid responsiveness so should be stepped up the COPD treatment ladder to a LAMA + LABA.",
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"id": "50297",
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"question": "Case Presentation: A 68 year old man attends his GP for a COPD review as he is feeling breathless.\n\n\n**PH** COPD, hypertension, hypercholesterolaemia\n\n**DH** salbutamol 200 micrograms INH QDS, amlodipine 10mg PO OD, atorvastatin 20mg PO OD. NKDA\n\n**On examination**\n\nTemperature 37.4°C, HR 74, RR 22, BP 115/78, O2 96% RA.\n\nAudible wheeze heard in all lung fields.\n\n**Investigations**\n\nHb 126, WCC 8.3, Plts 303 x 10<sup>9</sup>, eosinophils 0.1 x 10<sup>9</sup>L, CRP 2\n\nQuestion: Select the most appropriate management at this stage.",
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"explanation": "Conservative efforts to calm this patient down have failed, it is therefore indicated to prescribe a pharmacological agent that treats his agitation. In this case the gentleman has Parkinson's disease which means haloperidol should NOT be prescribed. In its place lorazepam 1mg PO OD should be prescribed as it does NOT actively block dopamine receptors like haloperidol does.",
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}
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"__typename": "QuestionComment",
"comment": "is there a section for delirium in BNF ",
"createdAt": 1674845120,
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"comment": "oh yeah, because i'm sure he's going to comply and actually swallow the meds. -_-",
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"comment": "is efforts to calming him down the same as re-orientating?",
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"question": "Case Presentation: A 78 year old man is currently an inpatient on the elderly care ward. The nursing staff are worried due to him exhibiting aggressive behaviour, he has struck one of the HCAs trying to assist him. Efforts to calm him down verbally have failed.\n\n**PH** Parkinson's disease, hypertension, hypercholesterolaemia\n\n**DH** Co-beneldopa 200mg PO BD, ramipril 5mg PO OD, atorvastatin 40mg PO OD. NKDA\n\n**On examination**\nTemperature 37.2°C, HR 84, RR 16, BP 134/82, O2 97% RA.\n\n**Investigations**\n\nBloods:\n\n- FBC: Hb 138, WCC 7.8, Plts 283 x 10^9\n- CRP 3\n- U&Es: Na 143, K 4.7, Ur 6.0, Cr 103 (baseline 100), eGFR >90mL/min/1.73m<sup>2</sup>\n- Ca2+ (adjusted): 2.3\n- Mg2+: 0.9\n- Phosphate: 0.83\n- LFTs: ALP 36, ALT 28, bilirubin 18\n- TFTs: TSH 1.2, T4 12, T3 7\n- Vitamin B12: 488 pg/ml\n\nMSU: no organisms detected.\n\nChest X-ray: no abnormalities detected.\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 3551,
"typeId": 1,
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173,458,849 | false | 16 | null | 6,494,976 | null | false | [] | null | 10,116 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is an incorrect option. This patient is in DKA and needs pharmacological intervention otherwise their condition will deteriorate.",
"id": "50311",
"label": "c",
"name": "Continue to monitor observations, blood glucose and blood ketones",
"picture": null,
"votes": 17
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
"id": "50309",
"label": "a",
"name": "Prescribe and give 500ml of 0.9% NaCl STAT first",
"picture": null,
"votes": 3323
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
"id": "50312",
"label": "d",
"name": "Prescribe and give a fixed rate insulin infusion of 1 units/kg/hour first",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.",
"id": "50310",
"label": "b",
"name": "Prescribe and give a fixed rate insulin infusion of 0.1 units/kg/hour first",
"picture": null,
"votes": 505
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Whilst you would want to give a fluid bolus first, 250ml is not enough. There is no evidence in the stem of the question that you should be concerned about fluid overload in this patient therefore 500ml STAT is an appropriate volume of fluid to give.",
"id": "50313",
"label": "e",
"name": "Prescribe and give 250ml of 0.9% NaCl STAT first",
"picture": null,
"votes": 331
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "BP syslotic is above 90 so you don't give NaCl STAT, it's given over an hour 1L",
"createdAt": 1675253103,
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"__typename": "QuestionComment",
"comment": "He's normotensive but still critically dehydrated. He is just compensating well. His intracellular and extravascular fluids are still low so you would still give stat fluids",
"createdAt": 1737733117,
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"comment": "even 500ml bolus in children?",
"createdAt": 1704728559,
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"comment": "Paediatric fluid bolus is 10mL/kg but we are not given his weight here...",
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"comment": "I think 16 is the cut off for adults, is it not?",
"createdAt": 1706115139,
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"comment": "i thought so too but i guess on average a 16yr old is prob around 40kg and so around 400 makes sense i guess... or in dka its always 500ml",
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"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": "The first line management of diabetic ketoacidosis",
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"topic": {
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"id": "91",
"name": "Paediatrics",
"typeId": 5
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"topicId": 91,
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"question": "Case Presentation: A 16 year old boy is brought to the emergency department with shortness of breath. His mother says he has been complaining of feeling really thirsty for the last couple days. \n\n\n\n\n **PH** Nil.\n\n\n **DH** Nil. NKDA\n\n\n **On examination**\nTemperature 37.6°C, HR 104, RR 24, BP 114/72, O2 95% RA.\n\n\nRespiratory exam: deep laboured breathing seen.\n\n\n **Investigations**\n\n||||\n|--------------|:-------:|------------------|\n|pH|7.31|7.35 - 7.45|\n|PaO₂|8.0 kPa|11 - 15|\n|PaCO₂|3.8 kPa|4.6 - 6.4|\n|Bicarbonate|23 mmol/L|22 - 30|\n\n\nBlood glucose: 22 mmol/L (<6.1 mmol/L)\n\n\nBlood ketones: 3.4 mmol/L (normal <0.6 mmol/L)\n\n\nQuestion: Select the most appropriate management at this stage.",
"sbaAnswer": [
"a"
],
"totalVotes": 4188,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,850 | false | 17 | null | 6,494,976 | null | false | [] | null | 10,118 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"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,
"votes": 2922
},
{
"__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
},
{
"__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
},
{
"__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",
"label": "c",
"name": "Amoxicillin 500mg PO TDS",
"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
}
],
"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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"id": "3647",
"name": "Prescribing antibiotics in a pregnant woman in her first trimester",
"status": null,
"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
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"topicId": 131,
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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.",
"sbaAnswer": [
"a"
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"typeId": 1,
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173,458,851 | false | 18 | null | 6,494,976 | 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": 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
},
{
"__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
}
],
"comments": [
{
"__typename": "QuestionComment",
"comment": "BNF says 1-2g every 6 hours of flucloxacillin? ",
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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 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.",
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173,458,852 | false | 19 | null | 6,494,976 | null | false | [] | null | 10,114 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50301",
"label": "c",
"name": "Add sitagliptin 100mg PO OD",
"picture": null,
"votes": 891
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin. She should be encouraged to keep taking metformin and keep any dietary/lifestyle changes she has employed and the HbA1c should be rechecked in 3 months.",
"id": "50299",
"label": "a",
"name": "Make no changes to her medications",
"picture": null,
"votes": 2561
},
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50303",
"label": "e",
"name": "Add 10 units Humulin I Insulin to take once in the morning",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50300",
"label": "b",
"name": "Add gliclazide 40mg PO OD",
"picture": null,
"votes": 1349
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.",
"id": "50302",
"label": "d",
"name": "Add pioglitazone 30mg PO OD",
"picture": null,
"votes": 251
}
],
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{
"__typename": "QuestionComment",
"comment": "when would you consider adding gliclazide here?",
"createdAt": 1703419810,
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"__typename": "QuestionComment",
"comment": "if HbA1c >58??",
"createdAt": 1703951918,
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"__typename": "QuestionComment",
"comment": "i thought the target is 48 mmol/mol with metformin alone, it's only 53 with hypo-causing meds?",
"createdAt": 1704971096,
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"__typename": "QuestionComment",
"comment": "same",
"createdAt": 1705108674,
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"comment": "the target is 48, but the threshold for considering adding another drug is 58. So her 53 is suboptimal target, but it is not necessary to add another drug. My guess is she would be given further dietary advice and exercise",
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"comment": "I agree with biopsy cystic! Though the target is 48, the threshold for adding another drug is 58!",
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"comment": "'If HbA1c levels are poorly controlled despite treatment with a single drug and rise to 58 mmol/mol (7.5%) or higher, drug treatment should be intensified, alongside reinforcement of advice regarding diet, lifestyle, and adherence to drug treatment.\n\nWhen two or more antidiabetic drugs are prescribed, a target HbA1c level of 53 mmol/mol (7.0%) is recommended for patients in which it is appropriate.''",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 73 year old woman attends her GP for a diabetes review. \n\n\n**PH** Type 2 diabetes mellitus, hypercholesterolaemia\n\n**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD. NKDA\n\n**Investigations**\n\nHbA1c 3 months ago: 62 mmol/mol (< 42 mmol/mol)\n\nHbA1c today: 53 mmol/mol (< 42 mmol/mol)\n\nQuestion: Select the most appropriate management at this stage.",
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173,458,853 | false | 20 | null | 6,494,976 | null | false | [] | null | 10,119 | {
"__typename": "QuestionSBA",
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"__typename": "QuestionChoice",
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"explanation": "Moderate-dose MART may be considered for patients whose asthma remains uncontrolled on low-dose MART. However, a stepwise approach is essential in asthma management, and since this patient has not yet trialed low-dose MART, moderate-dose MART would be premature at this stage.",
"id": "50324",
"label": "a",
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"picture": null,
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"explanation": "The patient's symptoms of nighttime wheezing and exercise limitation, coupled with an FEV1/FVC ratio of 53%, indicate suboptimal asthma control despite adherence to his current as-needed low-dose ICS/formoterol regimen. The most appropriate next step is to initiate low-dose daily maintenance and reliever therapy (MART), which involves using a low-dose ICS/formoterol combination both as a daily maintenance inhaler and as needed for symptom relief. ",
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"picture": null,
"votes": 2997
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"explanation": "This patient isn't having an acute asthma exacerbation nor is he at the point in the asthma treatment ladder in which oral corticosteroids would be considered (this would only be initiated by a specialist).",
"id": "50327",
"label": "d",
"name": "Add oral prednisolone 5mg PO OD",
"picture": null,
"votes": 94
},
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"__typename": "QuestionChoice",
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"explanation": "This patient isn't having an acute asthma exacerbation therefore this option is inappropriate.",
"id": "50328",
"label": "e",
"name": "Admit to hospital",
"picture": null,
"votes": 78
},
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"__typename": "QuestionChoice",
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"explanation": "Montelukast, a leukotriene receptor antagonist, is not typically considered as a first-line step in asthma management. It may be added as adjunct therapy if symptoms remain uncontrolled on moderate-dose MART. However, since the patient has not yet trialed low-dose or moderate-dose MART, montelukast is not indicated at this stage. ",
"id": "50325",
"label": "b",
"name": "Add montelukast 10 mg PO OD",
"picture": null,
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}
],
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"comment": "So essentially we're switching from AIR therapy to MART (PRN to regular)?",
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"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
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"question": "Case Presentation: A 26 year old man attends his GP for a review of his asthma. He is still feeling wheezy at night and struggling to exercise. His inhaler technique is good and he is taking his medications as recommended.\n\n**PMH** Asthma\n\n**DH** Low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as required\n\n**On examination**\n\nFEV1/FVC ratio: 53%\n\nQuestion: Select the most appropriate management at this stage.\n",
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173,458,854 | false | 21 | null | 6,494,976 | null | false | [] | null | 10,117 | {
"__typename": "QuestionSBA",
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"__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",
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"picture": null,
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"__typename": "QuestionChoice",
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"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
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"__typename": "QuestionChoice",
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"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": "QuestionChoice",
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"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
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"__typename": "QuestionChoice",
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"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
}
],
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"comment": "In another mock test it said to try sertraline first before mirtazapine kms",
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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",
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"comment": "where does it say on the BNF to use mirtazapine if appetite loss?",
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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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"comment": "Thought mirtazapine was cautioned in elderly?",
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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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173,458,855 | false | 22 | null | 6,494,976 | null | false | [] | null | 10,126 | {
"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Vertigo is a uncommon side effect of corticosteroid use therefore it is not likely that this patient will experience this.",
"id": "50363",
"label": "e",
"name": "He is likely to experience vertigo when taking prednisolone",
"picture": null,
"votes": 4
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"__typename": "QuestionChoice",
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"explanation": "Hepatic monitoring is not routinely performed for patients taking prednisolone.",
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"picture": null,
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"__typename": "QuestionChoice",
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"explanation": "Hyperhydrosis is a uncommon side effect of corticosteroid use therefore it is not likely that this patient will experience this.",
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"label": "b",
"name": "He is likely to experience excess sweating",
"picture": null,
"votes": 3
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"__typename": "QuestionChoice",
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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.",
"id": "50361",
"label": "c",
"name": "His height and weight should be monitored whilst taking prednisolone",
"picture": null,
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"__typename": "QuestionChoice",
"answer": true,
"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,
"votes": 2726
}
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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 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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"__typename": "QuestionSBA",
"choices": [
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hallucinations are a very rare side effect of enteral use of gentamicin.",
"id": "50357",
"label": "d",
"name": "She should report any hallucinations she experiences",
"picture": null,
"votes": 709
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "The frequency of vertigo occurring as a result of gentamicin treatment is unknown, therefore it is not something the patient needs to be told is likely to occur.",
"id": "50355",
"label": "b",
"name": "She is likely to experience vertigo when taking gentamicin",
"picture": null,
"votes": 541
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"__typename": "QuestionChoice",
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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.",
"id": "50354",
"label": "a",
"name": "Although this drug can cause acute kidney injury, it is safe to use in patients with chronic kidney disease",
"picture": null,
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"__typename": "QuestionChoice",
"answer": false,
"explanation": "Thyroid function is not routinely monitored in patients taking gentamicin.",
"id": "50356",
"label": "c",
"name": "She will need to have her thyroid function regularly monitored",
"picture": null,
"votes": 521
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Depression is a very rare side effect of gentamicin.",
"id": "50358",
"label": "e",
"name": "She is likely to experience changes to her mood when on gentamicin",
"picture": null,
"votes": 24
}
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{
"__typename": "QuestionComment",
"comment": "where could i find this info in the BNF ?",
"createdAt": 1737206357,
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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.'",
"createdAt": 1737655200,
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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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"__typename": "Concept",
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"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
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"id": "3654",
"name": "Gentamicin is safe to take in patients with chronic kidney disease",
"status": null,
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"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
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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.",
"sbaAnswer": [
"a"
],
"totalVotes": 2863,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,857 | false | 24 | null | 6,494,976 | null | false | [] | null | 10,121 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Isotretinoin has been linked to increased risk of depression and suicide therefore it is very important that the patient is informed to report any changes in their behaviour or mood after starting isotretinoin.",
"id": "50334",
"label": "a",
"name": "To report any changes in his mood or behaviour",
"picture": null,
"votes": 3756
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.",
"id": "50336",
"label": "c",
"name": "That he will require serum lipid monitoring every 6 months",
"picture": null,
"votes": 222
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.",
"id": "50338",
"label": "e",
"name": "That he will require annual visual acuity monitoring",
"picture": null,
"votes": 109
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nausea is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.",
"id": "50337",
"label": "d",
"name": "That he will likely experience nausea when taking isotretinoin",
"picture": null,
"votes": 12
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Dizziness is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.",
"id": "50335",
"label": "b",
"name": "That he will likely experience dizziness when taking isotretinoin",
"picture": null,
"votes": 18
}
],
"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,
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"id": "2657",
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"name": "Isotretinoin treatment increases the risk of low mood.",
"status": null,
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"__typename": "Topic",
"id": "91",
"name": "Paediatrics",
"typeId": 5
},
"topicId": 91,
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"question": "Case presentation: A 19-year-old man attends the dermatology clinic for his acne vulgaris medication. He has been taking tetracycline as instructed however his condition is not improving.\n\n\n\n**PH**\nAcne vulgaris\n\n**DH**\nTetracycline 500mg PO BD\n\nDue to his ongoing issues with his acne, his dermatologist commences him on isotretinoin.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 4117,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,858 | false | 25 | null | 6,494,976 | null | false | [] | null | 10,122 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Visual acuity is not routinely measured before starting pioglitazone.",
"id": "50343",
"label": "e",
"name": "Visual acuity should be measured before starting pioglitazone",
"picture": null,
"votes": 271
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There isn't an increased risk of prostate cancer when taking pioglitazone, there is however an increased risk of bladder cancer.",
"id": "50341",
"label": "c",
"name": "There is an increased risk of prostate cancer in patients who take pioglitazone",
"picture": null,
"votes": 25
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Incidence of heart failure is increased when patients use insulin and pioglitazone together. If the patient has a previous cardiac history such as a myocardial infarction, the risk is also increased. If a patient develops heart failure on pioglitazone (or already has heart failure), the pioglitazone should be stopped.",
"id": "50339",
"label": "a",
"name": "If he needs to use insulin alongside pioglitazone he is at an increased risk of developing heart failure",
"picture": null,
"votes": 699
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Renal function is not routinely measured before starting pioglitazone.",
"id": "50342",
"label": "d",
"name": "Renal function should be measured before starting pioglitazone",
"picture": null,
"votes": 34
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Insomnia is an uncommon side effect of pioglitazone, therefore it is not a likely side effect he will experience.",
"id": "50340",
"label": "b",
"name": "He is likely to experience insomnia after starting pioglitazone",
"picture": null,
"votes": 54
}
],
"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": [],
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"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3651",
"name": "Pioglitazone treatment increases the risk of heart failure",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
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"question": "Case presentation: A 78-year-old diabetic man attends an appointment with the diabetic nurse to monitor his blood glucose.\n\n\n\n**PH**\nType 2 diabetes mellitus, hypertension, hypercholesterolaemia\n\n**DH**\nMetformin 500mg PO BD, ramipril 10mg OD, amlodipine 10mg OD, atorvastatin 20mg PO OD.\n\nInvestigations: HbA1c 68 mmols/mol (<48 mmols/mol)\n\nAs this gentleman has a high HbA1c it is decided he should be started on another anti-diabetic medication. One of the medications offered to treat his diabetes includes pioglitazone.\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 1083,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,859 | false | 26 | null | 6,494,976 | null | false | [] | null | 10,127 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular blood pressure monitoring is only required in patients receiving IV nitrates.",
"id": "50366",
"label": "c",
"name": "He will need regular blood pressure monitoring",
"picture": null,
"votes": 499
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Regular heart monitoring is only required in patients receiving IV nitrates.",
"id": "50367",
"label": "d",
"name": "He will need regular heart rate monitoring",
"picture": null,
"votes": 73
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "GTN is administered sublingually (under the tongue), not into the buccal mucosa.",
"id": "50368",
"label": "e",
"name": "He should administer his GTN spray into the buccal mucosa",
"picture": null,
"votes": 1007
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Diarrhoea is an uncommon side effect of GTN therefore he is not likely to experience it.",
"id": "50365",
"label": "b",
"name": "He is likely to experience diarrhoea when taking GTN",
"picture": null,
"votes": 77
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Dizziness is a very common side effect of GTN, therefore when taking GTN it is advised that patient's sit down so that they do not fall.",
"id": "50364",
"label": "a",
"name": "He should sit down if possible when taking his GTN spray",
"picture": null,
"votes": 2490
}
],
"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": [],
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"demo": null,
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"id": "3656",
"name": "How to take GTN spray properly",
"status": null,
"topic": {
"__typename": "Topic",
"id": "9",
"name": "Internal Medicine",
"typeId": 5
},
"topicId": 9,
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"qaAnswer": null,
"question": "Case presentation: A 59-year-old man attends his GP complaining of chest pain. This chest pain is central, comes on with exercise and goes away with rest.\n\n\n\n\n\n\n **PH**\nHypertension\n\n\n **DH**\nRamipril 5mg PO OD\n\n\n **Investigations**\n\n\nECG - normal sinus rhythm\n\n\nTroponin I 3 ng/L (<14 ng/L)\n\n\nIt is decided that this gentleman has stable angina and should be given GTN (glyceryl trinitrate) spray for symptomatic relief.\n\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 4146,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,860 | false | 27 | null | 6,494,976 | null | false | [] | null | 10,123 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Acute illness can exaggerate the effect of warfarin and indicate a need to reduce dosage. Given this man has had a recent COVID-19 infection and his INR is out of therapeutic range for warfarin he will likely need his warfarin dose reducing.",
"id": "50344",
"label": "a",
"name": "His warfarin does should be reduced",
"picture": null,
"votes": 3005
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Renal function is not routinely monitored in patients using warfarin.",
"id": "50348",
"label": "e",
"name": "He is likely to need renal monitoring if his warfarin dose needs changing",
"picture": null,
"votes": 319
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "There are no interactions between ramipril and warfarin, it therefore does not need to be changed.",
"id": "50347",
"label": "d",
"name": "He should switch his ramipril to amlodipine due to potential interactions between ramipril and warfarin",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Nausea is a rare/very rare side effect of warfarin so he is unlikely to experience it with a dose change.",
"id": "50345",
"label": "b",
"name": "He is likely to experience nausea if his warfarin dose needs changing",
"picture": null,
"votes": 66
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "This is incorrect, concurrent illness can exaggerate the effect of warfarin which requires a reduction in dosage. This doesn't mean that you should completely stop this patients warfarin.",
"id": "50346",
"label": "c",
"name": "He needs to stop his warfarin immediately",
"picture": null,
"votes": 96
}
],
"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": "3652",
"name": "Warfarin requires increased monitoring in patients with liver disease/intercurrent illness",
"status": null,
"topic": {
"__typename": "Topic",
"id": "74",
"name": "Elderly Care",
"typeId": 5
},
"topicId": 74,
"totalCards": null,
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"qaAnswer": null,
"question": "Case presentation: A 74-year-old man attends warfarin clinic to have his INR checked. He has recently had COVID-19.\n\n\n\n**PH**\nAtrial fibrillation, hypertension, hypercholesterolaemia\n\n**DH**\n7.5mg warfarin PO OD, ramipril 5mg PO OD, atorvastatin 20mg PO OD\n\n**Investigations** INR 3.8 (2.0-3.0)\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 3514,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,861 | false | 28 | null | 6,494,976 | null | false | [] | null | 10,124 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metallic taste is not a listed side effect of unfractionated heparin.",
"id": "50353",
"label": "e",
"name": "He is likely to experience a metallic taste in his mouth as a side effect of unfractionated heparin",
"picture": null,
"votes": 82
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "This patient has chronic kidney disease stage 4, this means his eGFR is 15-29 ml/min. Hyperkalaemia is a recognised risk of chronic kidney disease, especially in the later stages of the disease. Unfractionated heparin inhibits aldosterone secretion, this in turn increases the risk of hyperkalaemia. As this patient is already predisposed to hyperkalaemia it is important to measure their potassium levels before giving unfractionated heparin and during their stay in hospital.",
"id": "50349",
"label": "a",
"name": "He will need to have his potassium checked before he has his heparin",
"picture": null,
"votes": 3328
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Alopecia is listed as a rare/very rare side effect of unfractionated heparin use, therefore they are not very likely to occur.",
"id": "50352",
"label": "d",
"name": "He is likely to experience hair loss whilst taking unfractionated heparin",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hepatic function is not routinely monitored in patients using unfractionated heparin.",
"id": "50350",
"label": "b",
"name": "He will need regular hepatic monitoring",
"picture": null,
"votes": 68
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Thyroid function is not routinely monitored in patients using unfractionated heparin.",
"id": "50351",
"label": "c",
"name": "He will need regular thyroid function tests for monitoring",
"picture": null,
"votes": 6
}
],
"comments": [],
"concept": {
"__typename": "Concept",
"chapter": {
"__typename": "Chapter",
"explanation": "Osteoporosis, otherwise known as thin bones, is a condition associated with high risk of low trauma fractures due to reduced bone mineral density. Osteoclast activity exceeds osteoblast activity, meaning that bone resorption is occurring at a greater rate than bone formation.\n\n**Symptoms and Signs**\n\n- Generally asymptomatic until a fragility fracture occurs\n- Back pain\n- Kyphosis (stooped posture)\n- Fragility fractures\n\n**Risk factors**\n\n- Female sex\n- Increasing age\n- Smoking\n- Corticosteroid use\n- Low BMI (< 20-25kg/m<sup>2</sup>)\n- Low body weight (<58kg)\n- Vitamin D deficiency\n\n**Protective factors**\n\n- Higher BMI\n- Exercise - mechanical loading stimulates bone formation\n\n**Diagnosis**\nOsteoporosis can be detected on dual-energy x-ray absorptiometry (DEXA) scan.\nA T score of < -2.5 indicates osteoporosis\n\n**Management**\n\n- Fall prevention\n- Vitamin D and calcium supplementation\n- Hormone replacement therapy (postmenopausal women)\n- Oral bisphosphonates",
"files": null,
"highlights": [],
"id": "2657",
"pictures": [],
"typeId": 5
},
"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3653",
"name": "Unfractionated heparin requires potassium levels to be measured prior to initiating treatment in patients with chronic kidney disease",
"status": null,
"topic": {
"__typename": "Topic",
"id": "13",
"name": "Neurosurgery",
"typeId": 5
},
"topicId": 13,
"totalCards": null,
"typeId": null,
"userChapter": null,
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"videos": []
},
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"id": "10124",
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"psaSectionId": 4,
"qaAnswer": null,
"question": "Case presentation: A 64-year-old man is admitted to hospital for elective surgery. He has known oesophageal cancer and is having a subtotal oesophagectomy to remove his tumour.\n\n\n\n**PH**\nOesophageal cancer, chronic kidney disease (stage 4)\n\n**DH**\nRamipril 10mg PO OD, atorvastatin 20mg PO OD, epoetin alfa 3500 units IV BD\n\nAs this gentleman is having surgery, he needs to be prescribed unfractionated heparin\n\nQuestion: Select the most important information that should be provided for this patient.",
"sbaAnswer": [
"a"
],
"totalVotes": 3499,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,862 | false | 29 | null | 6,494,976 | null | false | [] | null | 10,132 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Methotrexate does not commonly cause weight gain.",
"id": "50392",
"label": "d",
"name": "Methotrexate 20mg PO once weekly",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ibuprofen does not commonly cause weight gain.",
"id": "50393",
"label": "e",
"name": "Ibuprofen 400mg PO TDS",
"picture": null,
"votes": 2
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Folic acid does not commonly cause weight gain.",
"id": "50391",
"label": "c",
"name": "Folic acid 5mg PO once weekly",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Weight gain is a very common side effect of atypical antipsychotics. Olanzapine and clozapine are the atypical antipsychotics most likely to cause weight gain whereas atypical antipsychotics such as aripiprazole have a lower risk of causing weight gain.",
"id": "50389",
"label": "a",
"name": "Olanzapine 10mg PO OD",
"picture": null,
"votes": 3831
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol does not commonly cause weight gain.",
"id": "50390",
"label": "b",
"name": "Salbutamol 200micrograms INH QDS",
"picture": null,
"votes": 5
}
],
"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": [],
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"chapterId": 2657,
"demo": null,
"entitlement": null,
"id": "3661",
"name": "Olanzapine commonly causes weight gain",
"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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"question": "Case Presentation: A 34-year-old gentleman attends his GP complaining of weight gain. His regular medicines are listed (below).\n\n\n**PH** Asthma, Schizophrenia, Rheumatoid Arthritis\n\n**DH** Sertraline 50mg PO OD, Folic acid 5mg PO once weekly, Olanzapine 10mg PO OD, Methotrexate 20mg PO once weekly, Ibuprofen 400mg PO TDS\n\n**On examination**\n\nBP 129/69mmHg, HR 68, RR 14, Weight 89kg (84kg one month ago)\n\nQuestion: Select the medication that is most likely to have contributed to this patient's weight gain.",
"sbaAnswer": [
"a"
],
"totalVotes": 3848,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,863 | false | 30 | null | 6,494,976 | null | false | [] | null | 10,130 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Budesonide does not commonly interact with combined oral contraception",
"id": "50381",
"label": "c",
"name": "Budesonide 400 micrograms INH BD",
"picture": null,
"votes": 13
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Carbamazepine is a PY450 enzyme inducer, this is the enzyme responsible for the metabolism of the combined oral contraceptive pills. Increased activity of said enzyme results in the combined oral contraceptive pill being metabolised quicker and therefore having a lower efficacy. Other PY450 inducers include phenytoin, phenobarbital, felbamate, topiramate, oxcarbazepine and primidone.",
"id": "50379",
"label": "a",
"name": "Carbamazepine 200mg PO BD",
"picture": null,
"votes": 4633
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Cetirizine does not commonly interact with combined oral contraception",
"id": "50382",
"label": "d",
"name": "Cetirizine 10mg PO OD",
"picture": null,
"votes": 27
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Hydromol does not commonly interact with combined oral contraception",
"id": "50383",
"label": "e",
"name": "Hydromol cream one application to affected area BD",
"picture": null,
"votes": 5
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Salbutamol does not commonly interact with combined oral contraception",
"id": "50380",
"label": "b",
"name": "Salbutamol 200micrograms INH QDS",
"picture": null,
"votes": 6
}
],
"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": "3659",
"name": "Taking the combined oral contraceptive pill and carbamazepine reduces the efficacy of the combined oral contraceptive pill",
"status": null,
"topic": {
"__typename": "Topic",
"id": "131",
"name": "Obstetrics & Gynaecology/Paediatrics",
"typeId": 5
},
"topicId": 131,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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},
"conceptId": 3659,
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"highlights": [],
"id": "10130",
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"question": "Case Presentation: A 18-year-old woman attends her GP asking for the combined oral contraceptive pill. Her regular medicines are listed (below).\n\n\n**PH** Asthma, Epilepsy, Eczema, Allergic rhinitis\n\n**DH** Salbutamol 200micrograms INH QDS, Budesonide 400 micrograms INH BD, Carbamazepine 200mg PO BD, Cetirizine 10mg PO OD, Hydromol cream one application to affected area BD\n\nQuestion: Select the prescription that is most likely to reduce the efficacy of the combined oral contraceptive pill.",
"sbaAnswer": [
"a"
],
"totalVotes": 4684,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,864 | false | 31 | null | 6,494,976 | 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": 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": "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
},
{
"__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": "Hydroxychloroquine does not commonly cause constipation.",
"id": "50397",
"label": "d",
"name": "Hydroxychloroquine 200mg PO OD",
"picture": null,
"votes": 9
}
],
"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,
"typeId": null,
"userChapter": null,
"userNote": null,
"videos": []
},
"conceptId": 3662,
"conditions": [],
"difficulty": 1,
"dislikes": 5,
"explanation": null,
"highlights": [],
"id": "10133",
"isLikedByMe": 0,
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"likes": 0,
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"psaSectionId": 6,
"qaAnswer": null,
"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 |
173,458,865 | false | 32 | null | 6,494,976 | null | false | [] | null | 10,131 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril does not commonly cause hypercalcaemia.",
"id": "50385",
"label": "b",
"name": "Ramipril 10mg PO OD",
"picture": null,
"votes": 69
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause hypercalcaemia.",
"id": "50387",
"label": "d",
"name": "Atorvastatin 20mg PO OD",
"picture": null,
"votes": 15
},
{
"__typename": "QuestionChoice",
"answer": true,
"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
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Paracetamol does not commonly cause hypercalcaemia.",
"id": "50388",
"label": "e",
"name": "Paracetamol 1g PO QDS",
"picture": null,
"votes": 3
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Amlodipine does not commonly cause hypercalcaemia. In very rare cases it has been found to cause hypocalcaemia.",
"id": "50386",
"label": "c",
"name": "Amlodipine 10mg PO OD",
"picture": null,
"votes": 126
}
],
"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": "3660",
"name": "Indapamide can cause hypercalcaemia",
"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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},
"conceptId": 3660,
"conditions": [],
"difficulty": 1,
"dislikes": 0,
"explanation": null,
"highlights": [],
"id": "10131",
"isLikedByMe": null,
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"psaSectionId": 6,
"qaAnswer": null,
"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"
],
"totalVotes": 3227,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
173,458,866 | false | 33 | null | 6,494,976 | null | false | [] | null | 10,129 | {
"__typename": "QuestionSBA",
"choices": [
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Pioglitazone can cause peripheral oedema however this isn't as commonly seen as with amlodipine use.",
"id": "50378",
"label": "e",
"name": "Pioglitazone 30mg PO OD",
"picture": null,
"votes": 45
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Atorvastatin does not commonly cause peripheral oedema",
"id": "50377",
"label": "d",
"name": "Atorvastatin 200mg PO OD",
"picture": null,
"votes": 7
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Metformin does not commonly cause peripheral oedema",
"id": "50375",
"label": "b",
"name": "Metformin 500mg PO BD",
"picture": null,
"votes": 1
},
{
"__typename": "QuestionChoice",
"answer": false,
"explanation": "Ramipril does not commonly cause peripheral oedema",
"id": "50376",
"label": "c",
"name": "Ramipril 10mg PO OD",
"picture": null,
"votes": 28
},
{
"__typename": "QuestionChoice",
"answer": true,
"explanation": "Amlodipine is a common cause of peripheral oedema. Calcium channel blockers cause oedema by increasing the pressure within capillaries. This in turn causes fluid to leak out which results in peripheral oedema.",
"id": "50374",
"label": "a",
"name": "Amlodipine 5mg PO OD",
"picture": null,
"votes": 2669
}
],
"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": "3658",
"name": "A common side effect of amlodipine is peripheral oedema",
"status": null,
"topic": {
"__typename": "Topic",
"id": "92",
"name": "General Practice",
"typeId": 5
},
"topicId": 92,
"totalCards": null,
"typeId": null,
"userChapter": null,
"userNote": null,
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"question": "Case Presentation: A 61-year-old gentleman attends his GP complaining of ankle swelling. His regular medicines are listed (below). Weight 88kg.\n\n\n**PH** Type 2 diabetes mellitus, Hypertension, Hypercholesterolaemia\n\n**DH** Metformin 500mg PO BD, Ramipril 10mg PO OD, Amlodipine 5mg PO OD, Atorvastatin 200mg PO OD, Pioglitazone 30mg PO OD\n\n**On examination**\nBP 143/85mmHg, HR 74, RR 12, Weight 95kg\n\n**Investigation**\nChest clear, no added breath sounds. Heart sounds I + II present, no added sounds. Abdomen soft and non-tender.\n\nBilateral pitting oedema in both ankles.\n\nQuestion: Select the prescription that is most likely to have contributed to the patient's ankle swelling.",
"sbaAnswer": [
"a"
],
"totalVotes": 2750,
"typeId": 1,
"userPoint": null
} | MarksheetMark |
Subsets and Splits