MCEM MCQ Pharmacology

MCEM Pharmacology MCQ

1. Sedation (a) Midazolam has a short half life True False90min (b) Morphine is metabolised by the liver True False

(c) Pethidine has no active metabolites True False

(d) The Ramsay score is a useful index of sedative level True False1-6 from agitated to comatose (e) Fentanyl is a water soluble analgesic True FalseFar more lipid soluble than morphine which accounts for its rapid uptake and distribution

2. Of physiological changes in pregnancy (a) Cardiac output increases by around 30%. True False

(b) Diastolic BP drops slightly. True False

(c) pCO2 rises True FalsepCO2 falls slightly (d) HCO3- rises. True FalseHCO3- falls slightly

3. With regard to soft tissue infection:(a) Cellulitis is frequently caused by B-haemolytic streptococci. True FalseCellulitis is frequently caused by B-haemolytic streptococci. (b) The commonest organism causing myositis is staphylococcus aureus. True False

(c) The commonest organism causing myositis is clostridium perfringes. True FalseThe commonest organism causing myositis is clostridium perfringes. (d) Cellulitis is frequently caused by staphylococcus aureus. True FalseCellulitis is frequently caused by staphylococcus aureus. (e) Clostridium perfinges is a gram positive , anaerobic spore forming rod. True FalseClostridium perfinges is a gram positive , anaerobic spore forming rod.

4. Induction Drugs in Adults (a) The normal dose of thiopentol is 2-7mg/kg. True FalseThe normal dose of thiopentol is 2-7mg/kg. (b) The normal dose of etomidate is 0.3mg/kg True FalseThe normal dose of etomidate is 0.3mg/kg(c) The normal dose of propofol is 1.5-2.5 mg/kg True FalseThe normal dose of propofol is 1.5-2.5 mg/kg (d) The normal dose of ketamine is 1-2 mg/kg True FalseThe normal dose of ketamine is 1-2 mg/kg (e) Recovery time is generally longer after propofol than after ketamine True FalseRecovery time for ketamine is 15-30 minutes while recovery time for propofol is 5-10 minutes.

5. Adrenoreceptor affinity of sympathomimetics (a) Dobutamine has more affinity for alpha receptors than adrenaline True FalseAdrenaline has more affinity for alpha receptors than dobutamine. alpha-adrenoceptors exist on peripheral sympathetic nerve terminals and are divided into two subtypes alpha-1, and alpha-2. alpha-1 peripherally are responsible for contraction and are situated on vascular and on non-vascular smooth muscle.On the heart they mediate a positive inotropic effect alpha-2 receptors are located on liver cells, platelets, and the smooth muscle of blood vessels. Activation of these receptors causes platelet aggregation, and blood vessel constriction. (b) Noradrenaline has more affinity for alpha receptors than adrenaline True FalseNoradrenaline has more affinity for alpha receptors than adrenaline. (c) Phenylephrine has more affinity for beta 1 receptors than adrenaline True False


(d) Phenylephrine has poor affinity for beta 2 receptors True False

(e) Isoprenaline has affinity for beta 2 True Falseb1-receptors are largely postsynaptic and are located mainly in the heart but are also found in platelets, the salivary glands and the non-sphincter part of the gastrointestinal tract (GIT). They can however be found presynaptically. Activation causes an increase in the rate and contractile force of the heart, relaxation of the non-sphincter part of the GIT, aggregation of platelets and amylase secretion from the salivary glands. Presynaptically, their activation causes an increase in noradrenaline release. b2-receptors are also mainly postsynaptic and are located on a number of tissues including blood vessels, bronchi, GIT, skeletal muscle, liver and mast cell. Activation results in vasodilatation, bronchodilation, relaxation of the GIT, glycogenolysis in the liver, tremor in skeletal muscle and inhibition of histamine release from mast cells. b3-receptors are expressed predominately in adipose tissue activation is proposed to be involved with noradrenaline induced changes in energy metabolism via lipolysis and thermogenesis. b4-receptors are localised in cardiac tissue with activation causing an increase in heart rate and force.

6. The following are true: (a) The clearance of gabapentin is dependent on renal function. True FalseThe recommended dose of gabapentin in patients with creatinine clearance >60 ml/min is 1200 mg/day, but it is suggested that patients on haemodialysis start with a loading dose of 300?400 mg and then take 200?300 mg following each session of haemodialysis. (b) Gabapentin converts into a gamma-aminobutyric acid (GABA) agonist. True FalseGabapentin structurally resembles the neurotransmitter gamma-aminobutyric acid (GABA) but does not convert into GABA or a GABA agonist.(c) The average elimination half life of gabapentin in uraemic patients without haemodialysis is 4 hours.

True False

The average elimination half life of gabapentin in uraemic patients without haemodialysis is >100 hours. The average elimination half life of gabapentin in uraemic patients with haemodialysis is 4 hours. (d) Gabapentin can cause severe myoclonus True FalseGabapentin can cause severe myoclonus, myopathy, neutropaenia,lethargy, dizziness and altered consciousness.

7. Naloxone: (a) Is a specific u opioid receptor antagonist. True FalseNaloxone is an antagonist at all opioid receptors.(b) Reverses respiratory depression caused by pethidine. True False

(c) Both hypotension and hypertension may be caused by naloxone. True FalseBoth hypotension and hypertension may be caused by naloxone. Other side effects include ventricular tachycardia and fibrillation,cardiac arrest;hyperventilation, dyspnoea, pulmonary oedema. (d) Can cause pulmonary oedema True FalseThrough an unknown mechanism naloxone can cause pulmonary oedema.(e) May cause an increase in heart rate. True FalseNaloxone may cause an increase in heart rate.

8. The following statements about combination antibiotic therapy are correct. (a) Combinations of bacteriostatic and bacteriocidal drugs may impair their therapeutic efficacy. True False

(b) Combinations of bactericidal drugs are additive. True FalsePenicillins, cepahlosporins and aminoglycosides are examples of bactericidal drugs. (c) Combinations of bactericidal drugs may be synergistic. True False

(d) Combinations of bacteriostatic drugs are generally only additive. True False

(e) In septicaemic shock combination therapy should be avoided. True False

9. Nitrous Oxide (a) Onset of action is 3 to 5 minutes True False


(b) It must be delivered with 21% oxygen True FalseIt should be delivered with 30% oxygen to avoid hypoxia (c) Is contraindicated in patients with COPD True FalseAlso in patients with altered mental status, head injury or suspected pneumothorax(d) Should routinely be combined with IV opiates True FalseIt is an opiate agonist and the combination proposed may cause deep sedation (e) It's duration is 1 to 2 hours True FalseIts duration is 3 to 5 minutes after withdrawal

10. Beta-Blockers (a) The Beta receptor is coupled to a second messenger called cAMP True FalseThe Beta receptor(glycoprotein within the cell membrane ) is coupled to cAMP.(b) Stimulation of the beta receptor allows calcium entry into cells. True FalseStimulation of the beta receptor allows calcium entry into cells. (c) Stimulation of the beta2-receptors causes smooth muscle relaxation, which results in vasodilatation and brochodilation

True False

Stimulation of the beta2-receptors causes smooth muscle relaxation, which results in vasodilatation, and brochodilation. (d) Beta 1 activation promotes a faster and more forceful heart beat. True FalseBeta 1 activation promotes a faster and more forceful heart beat ( inotropy and chronotropy ) (e) The beta 1 subunit is located in the kidney and the eye. True FalseThe beta 1 subunit is located in the myocardium, the kidney and the eye.

11. Co-Amoxiclav(Augmentin) (a) Absorption is affected by food True FalseUnaffected. Peak serum levels one hour after oral administration.(b) Blocks bacterial beta lactamase enzymes True FalseAnd stops bacterial degradation (c) Is active against anaerobes True FalseAdvantage in treating pelvic infections(d) Recognised side effects include reversible cholestatic jaundice True FalseThought to be due to clavulinic acid (e) Is the anti-biotic of choice in treating animal bite wound infections True False

12. The following are true: (a) Warfarin is procoagulant in the first days of therapy. True FalseWarfarin is procoagulant in the first days of therapy. (b) Tamsulsoin relaxes the muscle of the prostate. True FalseTamsulosin relaxes the muscle of the prostate. (c) The ulnar nerve is blocked at the wrist between the ulnar artery and the tendon of flexor carpi radialis

True False

The ulnar nerve is blocked at the wrist between the ulnar artery and the tendon of flexor carpi ulnaris.(d) The median nerve is blocked between the tendons of palmaris longus and fleor carpi radialis. True FalseThe median nerve is blocked between the tendons of palmaris longus and fleor carpi radialis. (e) Omeprazole is a histamine receptor antagonist. True FalseOmeprazole is a proton pump inhibitor.

13. Warfarin (a) Inhibits gamma carboxylation of glutamyl residues of factor VII True FalseAnd factor II, IX, X (b) Onset of action is almost immediate True FalseDelayed until previously formed coagulation factors are used or metabolised (c) Has a prothrombotic effect on initiation True FalseAnd all patients should be heparinised on initiation(d) Has immunomodulatory effects on T Cells True False

(e) Half life is 6 hours True False36 hours


14. Gentamicin (a) Is effective in pneumococcal pneumonia True False

(b) Is poorly absorbed from the gut True False

(c) Has an elimination half life of 12 hours if renal function is normal True False

(d) CSF penetration is poor True False

(e) Causes irreversible VIII nerve damage True False

15. Which of the following are true: (a) Chlorpromazine(Largactil) has a lesser hypotensive effect than haloperidol. True FalseHaloperidol has a lesser effect on BP. (b) Calcium gluconate should not be given to patients on digoxin. True FalseCalcium gluconate should be used with caution in digitalized patients; hypercalcemia may precipitate cardiac arrhythmias.(c) 1mg of bumetanide is equal to 40 mg of furosemide. True False1mg of bumetanide is equal to 40 mg of furosemide. (d) IM administration of diazepam is well absorbed. True FalseIM injections of diazepam have unpredictable absorption.(e) Digoxin slows AV nodal conduction. True FalseIt is used for SVT and CHF. It slows AV conduction an acts as a Na,K,-ATPase inhibitor.

16. Amiodarone (a) Use with diltiazem may cause severe bradycardia. True FalseAmiodarone potentiates the effects of other medications which slow down the heart rate such as beta blockers and calcium channel blockers. Diltiazem and amiodarone may be a particularly bad combination (b) Amiodarone decreases digoxin levels True FalseAmiodarone increases digoxin levels (markedly reduce the digoxin dose and watch levels; or stop it) (c) Amiodarone may increase phenytoin levels True FalseAmiodarone may increase phenytoin levels (d) If sub-optimal arrhythmia control occurs the next step is to add a class I (Vaughan-Williams) agent such as disopyramide.

True False

If amiodarone is combined with Vaughan Williams class I agents then proarrhythmic effects (even polymorphic ventricular tachycardia) may be potentiated. This has been seen with propafenone, disopyramide and mexiletine. Marked QT prolongation may indicate high risk! Quinine and procainamide levels may also be increased on amiodarone therapy. Try and avoid using amiodarone with any class I agent. (e) Rifampicin increases amiodarone levels True FalseRifampicin increases amiodarone levels [ Pharmacotherapy 1999 Feb;19(2):249-51 ]

17. Paracetamol: (a) Side effects are rare. True False

(b) Hypotension is a known side effect. True FalseHypotension is associated with intravenous infusions of paracetamol. (c) Recent evidence suggests paracetamol can be a drug of abuse. True False

(d) Use with particular caution in alcohol dependence. True False

(e) Caution use per rectum in children aged 1- 5 years. True False

18. Local Anaesthesia (a) The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine True False

(b) For a femoral nerve block the local anaesthetic agent should be injected medial to the femoral True False


arteryThe local anaesthetic should be injected laterally as the nerve is lateral to the artery(c) Lignocaine 1% contains 1mg of lignocine per ml of solution True False10mg/ml of solution (d) Lignocaine has a half life of 10 hours True FalseLignocaine has a half life of 2 hours(e) Biers block is used as anaesthesia for colles fractures True False

19. Medications in Pregnancy: (a) Antithyroid drugs such as carbimazole are not associated with neonatal hypothyroidism. True FalseAntithyroid drugs such as carbimazole may cause neonatal hypothyroidism (b) Glucocorticoids do not cross the placenta in normal pregnancy. True FalseGlucocorticoids may cause neonatal adrenal suppression in high doses. (c) Warfarin is associated with vestibular nerve impairment. True FalseWarfarin is associated with bone abnormalities and neonatal haemorrhage (d) Beta blockers are safe in pregnant women with hypertension. True FalseBeta blockers may cause growth retardation (e) Carbamazepine is associated with neonatal goitre. True FalseCarbamazepine is associated with neural tube defects

20. Cardiac Glycosides: (a) Digoxin is positively inotropic and is renally excreted. True FalseDigoxin is positively inotropic and is renally excreted. (b) Digoxin increases vagal tone and decreases conduction through the AV node True FalseDigoxin increases vagal tone and decreases conduction through the AV node (c) The half life of therapeutic dose digoxin is about 12 hours True FalseThe half life of therapeutic dose digoxin is about 48 hours. (d) Digoxin activates the Na/K/ATPase pump. True FalseDigoxin inactivates the Na/K/ATPase pump (e) Hypokalaemia but not hypomagnesemia increases the likelihood of digoxin toxicity. True FalseBoth hypokalaemia and hypomagnesemia increase the likelihood of digoxin toxicity.

21. Opioid analgesics(a) 3mg oral morphine is about equivalent to 10mg oral codeine True False3mg oral morphine is about equivalent to 20mg oral codeine(b) 3mg oral morphine is about equivalent to 5mg oral oxycodone True False3mg oral morphine is about equivalent to 1.5mg oral oxycodone (c) 1mg IV morphine is about equivalent to 3mg po morphine True False1mg IV morphine is about equivalent to 3mg po morphine (d) True allergic reactions are common True FalseTrue allergic reactions are extremely rare (e) The classes of opioids include the phenanthrene derivatives, the phenylpiperidine derivatives, and the diphenylheptane derivatives

True False

22. Digoxin: (a) The half life of therapeutic dose digoxin is about 48 hours. True FalseThe half life of therapeutic dose digoxin is about 48 hours.(b) Digoxin inactivates the Na/K/ATPase pump. True FalseDigoxin inactivates the Na/K/ATPase pump (c) Digoxin is negatively inotropic and is renally excreted. True FalseDigoxin is positively inotropic and is renally excreted.(d) Digoxin decreases vagal tone and decreases conduction through the AV node. True FalseDigoxin increases vagal tone and decreases conduction through the AV node (e) Both hypokalaemia and hypomagnesemia increase the likelihood of digoxin toxicity. True FalseBoth hypokalaemia and hypomagnesemia increase the likelihood of digoxin toxicity.

23. The following are true:(a) NSAIDS augment the conversion of arachidonic acid to thromboxanes, prostacyclins and prostaglandins

True False


NSAIDS inhibit the conversion of arachidonic acid to thromboxanes, prostacyclins and prostaglandins (b) NSAIDs inhibit the conversion of arachidonic acid to leukotrienes True False

(c) NSAIDs inhibit the conversion of membrane phospholipids to arachidonic acid True False

(d) Cyclooxygenase converts arachidonic acid to thromboxanes, prostacyclins and prostaglandins True FalseCyclooxygenase converts arachidonic acid to thromboxanes, prostacyclins and prostaglandins (e) Lipoxygenase inhibits the conversion of arachidonic acid to leukotrienes True FalseLipoxygenase converts arachidonic acid to leukotrienes Membrane phospholipids are converted to arachidonic acid by phospholipase A2. Arachidonic Acid is converted to thromboxanes, prostacyclins and prostaglandins by cyclooxygenase.Lipoxygenase converts Arachidonic acid to leukotrienes www.medscape.com

24. Amiodarone (a) Lung toxicity may occur in up to 2% of patients on long term therapy. True FalseThis is be significant in 3 to 9% of patients (possibly even up to 17%), and may kill the patient if missed. There may be: Interstitial pneumonitis Lung fibrosis Hypersensitivity pneumonitis Bronchiolitis obliterans organising pneumonia (BOOP) has been reported. [ Neth J Med 1998 Sep;53(3):109-12 ] (b) Onset of lung toxicity may be delayed for 3 years after starting amiodarone True FalseOnset of toxicity may be delayed for 3 years after starting amiodarone (c) Neurotoxicity may manifest as proximal myopathy,distal sensory disturbance or peripheral neuropathy.

True False

Neurotoxicity has been reported in up to 40%, manifesting mainly as peripheral neuropathy with proximal motor weakness or distal sensory disturbance. Sleep disturbance, ataxia, vivid dreams and fine resting tremor are said to be common, and worse in the elderly. (d) Phototoxicity is a rare adverse effect. True FalsePhototoxicity is common and is a response to UVA. Blue-Grey skin discoloration may occur, as well as itch, petechiae and erythema nodosum. (e) Hyperthyroidism may occur but not hypothyroidism. True FalseBoth hypo and hyperthyroidism may occur.

25. Lactulose (a) Is an osmotic laxative True FalseIt is a non absorbed disaccharide (b) May be used by diabetics True FalseDespite very sweet taste 15ml contains 14 kcals (c) Recognised side effects include increased flatus True FalseSo increase dose slowly (d) Is a useful drug in the treatment of hepatic encephalopathy True FalseDiscourages the proliferation of ammonia producing organisms(e) May take up to 48 hours before side effects are obtained True FalseAlso has a carry over effect


vancomycin: (a) Is a broad spectrum antibiotic. False ?Gram positives. (b) Is active against MRSA. True ? (c) Commonly produces nephrotoxicity. True ? (d) May cause red man syndrome. True ?Particularly if infused too quickly. (e) Is indicated in the treatment of antibiotic associated colitis. True ?Is indicated in the treatment of antibiotic associated colitis.


Emergency treatment of bradycardias:

(a) May be treated with atropine. True (b) May be treated with transcutaneous cardiac pacing. True (c) May be treated with internal pacing. True (d) Should be initiated even without evidence of hypoperfusion. False (e) Treatment is not required if the bradydysrhythmia is due to disease of the infranodal conduction system. False Bradydysrhythmia can be caused by 2 mechanisms. Depression of the SA nodal activity or conduction system blocks.Subsidiary pacemakers take over the pacing of the heart, and provided the pacemaker is located above the bifurcation of the His bundle, the rate is generally adequate to maintain cardiac output. The need for emergent treatment should be guided by 2 considerations,1.evidence of hypoperfusion or 2. the bradydysrhythmia is due to structural disease of the infranodal conductiong system that may degenerate into complete AV block or asystole.


Opioid Analgesics (a) The classes of opioids include the phenanthrene derivatives, the phenylpiperidine derivatives, and the diphenylheptane derivatives True ?The classes of opioids include the phenanthrene derivatives, the phenylpiperidine derivatives, and the diphenylheptane derivatives (b) True allergic reactions are extremely rare True ?Opiate hypersensitivity is uncommon and true allergic reactions are extremely rare (c) 1mg IV morphine is about equivalent to 5mg po morphine False ?1mg IV morphine is about equivalent to 3mg po morphine (d) 3mg oral morphine is about equivalent to 1.5mg oral oxycodone True ?3mg oral morphine is about equivalent to 1.5mg oral oxycodone (e) 3mg oral morphine is about equivalent to 20mg oral codeine True ?3mg oral morphine is about equivalent to 20mg oral codeine


Salbutamol (a) Produces significant bronchodilatation within 2 to 3 minutes False ?Within 15 minutes (b) Use is contraindicated in patients with co-existing heart disease False ?Very little effect on the heart and regarded as safe (c) Is of no value in preventing exercise induced asthma attacks False ?Two puffs prior to exertion likely to be effective (d) Duration of action is 2 to 3 hours False ?Effects last longer than this (e) Delivers 400 doses per canister False ?200.Terbutaline(Bricanyl) inhaler delivers 400.


Regarding muscles of the orbit: (a) Levator palpabrae superioris is supplied by the oculomotor nerve. True Levator palpabrae superioris is supplied by the oculomotor nerve. (b) Lateral rectus is an abductor of the eyeball. True Lateral rectus is an abductor of the eyeball. (c) Superior rectus turns the eye upwards and laterally. False The action of superior rectus is to turn the eye upwards and medially. (d) Superior oblique loops through a fascial sling before attaching to the eyeball. True Superior oblique loops through a fascial sling before attaching to the eyeball.


Adenosine (a) Can be given orally False ? (b) Should be given as a 6 mg infusion over 10 min False ?Push (c) Has a plasma half life of 10 mins False ?<2seconds (d) Chest pain is a well recognised complication True ? (e) Can cause flushing, breathlessness and hypotension True


Drug Reactions: (a) Type III reactions ( arthrus, serum sickness or immune complex ) is caused by the formation of antibody-antigen complexes which lodge in the small blood vessels of the skin, kidney, and joints. True ?Type III reactions ( arthrus, serum sickness or immune complex ) is caused by the formation of antibody-antigen complexes which lodge in the small blood vessels of the skin, kidney, and joints. (b) Type III reactions may mimic SLE True ?Type III reactions may mimic SLE (c) Sulphonmamides and streptomycin are associated with type II reactions False ?Penicillin?s, sulphonmamides and streptomycin are associated with type III reactions (d) Carbimazole and prophylthiouracil are associated with type II reactions False ?Carbimazole and prophylthiouracil are associated with type III reactions (e) Type III reactions present several days following the initiation of therapy True ?Type III reactions present several days following the initiation of therapy


Nitrous Oxide (a) Has opiate agonist properties True ?Which is relevant if given concurrently with an opiate. (b) Must be delivered with O2 True ?To avoid hypoxia (c) May cause nausea and vomiting. True ?This is the commonest side effect (d) Duration of action is 30 min False ?Duration of action is 3-5 min (e) Is contraindicated in pneumothorax but safe for patients with altered mental status. False ?Is contraindicated in patients with altered mental status, head injury, suspected pneumothorax, COPD, perforated viscus and eye injuries.


Recognised adverse reactions to aspirin include (a) Erythema Nodosum True ?Also urticaria and erythema multiforme (b) Purpura True ?And epistaxis and occasional thrombocytopaenia (c) In high doses, increased blood pressure True ?it can cause sodium retention (d) In high doses, gout False ?At high doses aspirin inhibits tubular resorption of uric acid (e) Stomatitis True ?And mouth ulcers and taste disorders


In Pregnancy (a) Metronidazole should be avoided in the first trimester. True ? (b) Penicllin may be used True ? (c) Cephalosporins may be used True ? (d) Nitrofurantoin may be used True ? (e) Clindamycin may be used True ? All the above are category B drugs. They are presumed safe and safe in animal studies


Local Anaesthetic (a) The duration of action of lignocaine is 30-60min. True ? (b) The maximum dose of lignocaine which can be given with epiephrine/adrenaline is lower than the maximum dose of lignocaine which can be given without epinephrine/adrenaline. False ?The maximum dose of lignocaine which can be given with epiephrine/adrenaline is higher than the maximum dose of lignocaine which can be given without epinephrine/adrenaline. (c) 1% lignocaine is 1mg/ml False ?1% lignocaine is 10mg/ml (d) Procaine is an amide local anaesthetic. False ?Procaine is an ester local anaesthetic. (e) Lignocaine is an amide local anaesthetic True ?Lignocaine is an amide local anaesthetic


Regarding blood products (a) Group O is the universal recipient. False AB is the universal recipient, O is the universal donor (b) Whole blood more than 2 days old contains no effective platelets. True (c) A slow rising temperature (<40?C) represents an ABO incompatibility and the transfusion must be stopped immediately. False a slow rising temperature (<40?C) is usually due to antibodies against white cells (d) Platelet concentrates are stored at ?30?C. False platelet concentrates are stored at 22?C for up to 5 days, FFP is stored at ?30?C


Adenosine is contraindicated in the following circumstances: (a) Asthma. True ?May cause bronchospasm. However the literature is conflicting in this topic as according to bestbets.org 'At worst adenosine is only relatively contraindicated in the treatment of asthmatic patients with supraventricular tachycardia.' (b) 2nd degree heart block. True ?Adenosine is contraindicated in 2nd degree heart block. (c) 1st degree heart block. False ?Adenosine is not contraindicated in 1st degree heart block. (d) 3rd degree heart block. True ?Adenosine is contraindicated in 3rd degree heart block. (e) Sick Sinus Syndrome True ?Adenosine is contraindicated in sick sinus syndrome.


The following medications are enzyme inhibitors (a) Allopurinol True (b) Erythromycin True (c) Valproate True (d) Sulphonamides True (e) Phenytoin False A memory aid for enzyme inhibitors is AO Devices...allopurinol,omeprazole,disulfiram,erythromycin,valproate,isoniazid,cimetidine,ethanol intoxication, sulphonamides. Phenytoin is an enzyme inducer.


Interferons: (a) Myelosuppression is a side effect. True ? (b) The metabolism of warfarin is impaired. True ?And phenytoin. (c) Is safe to use in pregnancy. False ?Contraindicated. (d) 50% of patients with hepatitis B obtain a long term response. True ?20% of Hepatitis C patients. (e) Metabolism of cimetidine is unaffected. False ?There is decreased activity of certain cytochrome p450 enzymes affecting the metabolism of cimetidine, theophylline, diazepam, and propranolol.


Acute phase proteins: (a) Include coagulation factors such as fibrinogen, prothrombin and factor VIII. True Acute phase proteins include coagulation factors such as fibrinogen, prothrombin and factor VIII. (b) Can facilitate phagocytotic uptake of bacteria. True e.g. C reactive protein aids in the phagocytosis of pneumococci (c) Are synthesised by the liver in response to inflammation. True Acute phase proteins are synthesised by the liver in response to inflammation. (d) Include ferritin. True Acute phase proteins include ferritin.


Anaphylaxis: (a) The initial adrenaline dose is usually 0.5mg ( 0.5ml of 1:10000 ) IM. False ?The initial adrenaline dose is 0.5mg ( 0.5ml of 1:1000 ) IM. (b) The dose of adrenaline should be reduced if the patient is taking TCAs or MAOIs. True ?The dose of adrenaline should be reduced if the patient is taking TCAs, MAOIs or beta blockers. (c) The dose of adrenaline should be reduced if the patient is taking beta agonists. False ?The dose of adrenaline should be reduced if the patient is taking TCAs, MAOIs or beta blockers. (d) A patient can be discharged once symptoms have settled. False ?A patient should be observed for 4-6 hours after symptoms have settled for biphasic reactions. (e) Angio-oedema can be caused by ACE inhibitors. True ?Angio-oedema can be caused by ACE inhibitors.


Adenosine side effects: (a) Dyspnoea. True ? (b) Cough. True ? (c) Chest Pain. True ? (d) PVCs. True ? (e) Hypotension. True ? Also facial flushing, syncope, vertigo, paraesthesias, numbness, nausea, metallic taste.


Paraquat: (a) Often causes an ARDS picture. True ?Paraquat often causes an ARDS picture. (b) Pulmonary fibrosis usually develops in the second week. True ?Pulmonary fibrosis usually develops in the second week. (c) Liver failure may occur. True ?Liver failure may occur. (d) Myocarditis may occur. True ?Myocarditis may occur. (e) The dose ingested is a predictor of outcome. True ?The dose ingested is a predictor of outcome. Death universal after 50ml(10g). Death reported after10-15mls of 20% solution(3g)


Hypertension in the Emergency Department: (a) Patients with a diastolic blood pressure greater than 110mmHg should be referred to the in-house medical team. True ?Patients with a diastolic blood pressure greater than 110mmHg should be referred to the in-house medical team or if there is evidence of hypertensive encephalopathy. (b) Sodium Nitroprusside has a half life of 10 minutes. False ?Sodium Nitroprusside has a short half life of 1-2 minutes. (c) Sodium Nitroprusside is a dilator of arterioles but not veins. False ?Sodium Nitroprusside is a dilator of arterioles and veins. (d) IV labetalol is a preferred option to IV sodium nitroprusside if the patient has an aortic dissection. True ?IV labetalol is a preferred option to IV sodium nitroprusside if the patient has an aortic dissection or phaeochromocytoma.


Opioid Analgesics: (a) IV Fentanyl has a longer duration of action than IV morphine. False ?Fentanyl IV lasts 30-40 min Morphine IV lasts 1-2 hours (b) The duration of IV morphine is about 1-2 hours. True ?The duration of IV morphine is about 1-2 hours while the onset of effect is within 5 minutes. (c) Codeine is metabolised to morphine. True ?Small amounts of codeine are metabolised to morphine. (d) The duration of action of codeine is about 4 hours. True ?30-60mg is an appropriate initial oral dose for acute severe pain. (e) Morphine may result in an anaphylactoid reaction because of histamine release. True ?Morphine may result in an anaphylactoid reaction because of histamine release.


Adverse Drug Reactions: (a) The most common target for Type I reactions is the haematological system ( resulting in Coombs positive haemolytic anaemia or thrombocytopaenia False ?The most common target for Type II reactions is the haematological system ( resulting in Coombs positive haemolytic anaemia or thrombocytopaenia (b) Methyldopa and Pencillin?s are associated with Type III reactions causing Coombs positive haemolytic anaemia. False ?Methyldopa and Pencillin?s are associated with Type II reactions causing Coombs positive haemolytic anaemia. (c) Quinine is associated with Type II reactions causing thrombocytopaenia True ?Quinine is associated with Type II reactions causing thrombocytopaenia (d) Agranulocytosis and marrow aplasia are associated with a type I reaction. False ?Agranulocytosis and marrow aplasia are associated with a type II reaction. (e) Type II reactions because of a drug reacting with a circulating or membrane bound protein to cause production of an IgA or IgE antibody with subsequent complement activation False ?Type II reactions because of a drug reacting with a circulating or membrane bound protein to cause production of an IgG or IgM antibody with subsequent complement activation


Digoxin Toxicity May Be Enhanced By: (a) Hyperkalaemia False ?Hypokalaemia predisposes to digoxin toxicity and hyperkalaemia may be seen in acute poisonings because of the Na/K/ATPase Dysfunction. (b) Hypocalcaemia False ?Hypercalcaemia predisposes to digoxin toxicity. (c) Hypomagnesemia True ?Hypomagnesemia predisposes to digoxin toxicity (d) Hypothyroidism True ?COPD , renal impairment and hypothyroidism predispose to digoxin toxicity. (e) Beta blockers True ?Ca channel blockers ,beta blockers and amiodarone potentiate digitalis toxicity.


Drug Reactions: (a) Type IV reactions are cell mediated hypersensitivity reactions caused by the formation of an antigen-protein complex and subsequent lymphocytic reaction. True ?Type IV reactions are cell mediated hypersensitivity reactions caused by the formation of an antigen-protein complex and subsequent lymphocytic reaction. (b) Type III reactions may cause fever, urticaria, arthropathy, lymphadenopathy and proteinuria. True ?Type III reactions may cause fever, urticaria, arthropathy, lymphadenopathy and proteinuria. (c) Type III reactions do not cause eosinophilia. False ?Type III reactions cause eosinophilia (d) Type I reactions activate the complement system via IgG and IgM. False ?Type II reactions activate the complement system via IgG and IgM (e) Type II reactions cause coombs positive haemolytic anaemia True ?Type II reactions cause coombs positive haemolytic anaemia


Acute epididymitis (a) Commonly results from chlamydia or gonorrhoea infection in the <35yr age group. True (b) Testicular torsion is an important differential diagnosis. True (c) The opposite testicle is seen to lie horizontally rather than vertically (Angells Sign). False This is a sign of testicular torsion (in epididymitis the testes often lie low in the scrotum) (d) Appropriate first line antibiotic therapy would include ciprofloxacin. True


Medications used for Atrial Fibrillation: (a) There is often hyperkalaemia in patients with acute digoxin toxicity because of Na/K/ATPase pump dysfunction. True ?There is often hyperkalaemia in patients with digoxin toxicity because of Na/K/ATPase pump dysfunction.This is more common in acutely poisoned patients. (b) The clinical presentation of digoxin toxicity may mimic a common illness such as a flu like illness or a gastroenteritis. True ?The clinical presentation of digoxin toxicity may mimic a common illness such as a flu like illness or a gastroenteritis. (c) Ca channel blockers but not beta blockers potentiate digitalis toxicity. False ?Ca channel blockers and beta blockers potentiate digitalis toxicity. (d) Junctional escape rhythms, 1st degree AV block but not premature ventricular beats are associated with digitalis toxicity. False ?Moorman JR, Pritchett EL: The arrhythmias of digitalis intoxication. Arch Intern Med 145:1289, 1985 (e) Patients with digoxin toxicity can complain of seeing yellow green halo?s around objects. True ?Patients with digoxin toxicity can complain of seeing yellow green halo?s around objects.


Regarding vasopressors and inotropes (a) Phenylephrine is a selective alpha agonist. True (b) Noradrenaline decreases afterload and is therefore appropriate for use in cardiogenic shock. False Noradrenaline increases afterload and therefore is not appropriate in cardiogenic shock (c) Metaraminol induces release of noradrenaline and adrenaline. True (d) The adult dose of IM adrenaline for use in anaphylactic shock is 0.5mL of 1:10,000. False The correct adrenaline dose is 0.5mL of 1:1000 when used intramuscularly


The following are true: (a) The anticoagulant effect of warfarin is inhibited by fluconazole. False ?The anticoagulant effect of warfarin is enhanced by fluconazole and other anti-fungals. (b) The anticoagulant effect of warfarin is reduced by amiodarone. False ?The anticoagulant effect of warfarin is enhanced by amiodarone as metabolism is inhibited. (c) The anticoagulant effect of warfarin is enhanced by ciprofloxacin. True ?The anticoagulant effect of warfarin is enhanced by ciprofloxacin. (d) There is an increased risk of bleeding when tramadol is given with warfarin. True ?There is an increased risk of bleeding when tramadol is given with warfarin.


Prednisolone use is contraindicted in: (a) Hypertension False Caution to be exercised but not contraindicated (b) Diabetes Mellitus False Caution to be exercised but not contraindicated (c) Epilepsy False Caution to be exercised but not contraindicated (d) Systemic infection True ? (e) History of steroid myopathy False Caution to be exercised but not contraindicated


Recognized side effects of local steroid injections (a) Pain at the time of injection True ?And is therefore often combined with lignocaine (b) Subcutaneous Hypertrophy False ?Atrophy may be seen (c) Skin Pigmentation False ?Skin depigmentation (d) Infection True ?Although rare (e) Systemic toxicity False ?Not a problem


Amiodarone (a) Has a half life of 50 days True ? (b) Is used in re-entrant AV tachcardias caused by wolf-parkison white syndrome True ?Effective in 50-75% of patients (c) A minority of patients will develop corneal deposits False ?Almost all (d) Skin sensitisation to UVA is common True ? (e) Thyroid function derangement occurs in 2% True ?


Ketamine: (a) May cause dry mucous membranes. False ?Ketamine may cause hypersalivation. (b) Reduces intracranial pressure. False ?Ketamine increases intracranial pressure. (c) Is safe in patients with cardiovascular disease. False ?Is relatively contraindicated in patients with cardiovascular disease as it is a myocardial depressant and vasodilator. (d) May cause bronchoconstriction. False ?May cause bronchodilation, laryngospasm, hypersalivation. (e) Causes respiratory depression. True ?True but minimal respiratory depression.


Adenosine (a) Half life is 30 min in vivo False ?2 seconds (b) Never cardioverts patients in A flutter False ?10% will cardiovert (c) Is effective in terminating re-entrant tachy arrhythmias True ?90% of AVRT's and AVNRT's will be stopped (d) May be useful to slow down an atrial tachycardia to reveal A Fib True ? (e) Should never be used in broad complex tachycardia False ?


In pregnancy (a) MMR may be given False (b) Tetanus and diptheria may be given True ? (c) Pneumococcal vaccine may be given True ? (d) Hepatitis B vaccine may be given True ? (e) Influenza vaccine may be given True ? The only contraindicated vaccines are live vaccines such as the MMR. Others should be considered with care.


Ciclosporin (a) Is associated with hypokalaemia False ?Ciclosporin is associated with hyperkalaemia, especially in renal impairment patients. (b) Is associated with hypotension False ?Ciclosporin is associated with hypertension and should be discontinued if hypertension develops which is resistant to treatment. (c) Is associated with gingival hypertrophy True ?Is associated with hypertrichosis, headache, tremor, hypertension, gingival hypertrophy, GI disturbance and burning sensation's in the hands and feet. (d) Is associated with burning sensation in the hands and feet. True ?Is associated with hypertrichosis, headache, tremor, hypertension, gingival hypertrophy, GI disturbance and burning sensation's in the hands and feet.


Metronidazole is used to treat: (a) Trichomonal infection. True ?Metronidazole is used to treat trichomonal infection. (b) Amoebic dysentry. True ?Metronidazole is used to treat amoebic dysentry. (c) Giardiasis. True ?Metronidazole is used to treat giardiasis. (d) Tetanus. False ? (e) Gas gangrene. True ?Metronidazole is used to treat gas gangrene. Highly active against amoebae.


Drugs and antidotes (a) Digoxin-Specific antibody True ?Therapeutic plasma range is 1.3-2.6 nmol/L. Toxic levels occur at >2.6 nmol/L (b) Phenothiazines-Benztropine True ? (c) Benzodiazepines-Flumazenil True ? (d) Salbutamol- B-Blockers True ? (e) B-Blockers-Glucagon True


Warfarin: (a) Hirsutism is a known side effect. False ?Alopecia. (b) Skin necrosis is a known side effect. True ?Skin necrosis is a known side effect. (c) Metronidazole increases warfarin effect. True ?Metronidazole increases warfarin effect. (d) Cholestyramine increases warfarin absorption. False ?Reduces. (e) Co-trimoxazole increases warfarin effect. True ?Co-trimoxazole increases warfarin effect.


Amiodarone (a) Use with diltiazem is indicated for prophylaxis of severe bradycardia. False ?Amiodarone potentiates the effects of other medications which slow down the heart rate such as beta blockers and calcium channel blockers. Diltiazem and amiodarone may be a particularly bad combination (b) Amiodarone increases digoxin levels True ?Amiodarone increases digoxin levels (markedly reduce the digoxin dose and watch levels; or stop it) (c) Amiodarone may decrease phenytoin levels False ?Amiodarone may increase phenytoin levels (d) If sub-optimal arrhythmia control occurs the next step is to add a class I (Vaughan-Williams) agent such as disopyramide. False ?If amiodarone is combined with Vaughan Williams class I agents then proarrhythmic effects (even polymorphic ventricular tachycardia) may be potentiated. This has been seen with propafenone, disopyramide and mexiletine. Marked QT prolongation may indicate high risk! Quinine and procainamide levels may also be increased on amiodarone therapy. Try and avoid using amiodarone with any class I agent. (e) Rifampicin increases amiodarone levels True ?Rifampicin increases amiodarone levels [ Pharmacotherapy 1999 Feb;19(2):249-51 ] www.anaesthetist.com


Procedural Sedation and Analgesia(PSA) reversal: (a) The intravenous dose of naloxone in poisoning is 0.4-2mg every 2-3 minutes repeated to a max dose of 10mg. True ?The intravenous dose of naloxone in poisoning is 0.4-2mg every 2-3 minutes repeated to a max dose of 10mg. (b) The initial intravenous dose of flumazenil for reversal of PSA is 200mcg over 15 minutes. False ?The initial intravenous dose of flumazenil is 200mcg over 15 seconds, then 100mcg at 60 second intervals if required.The maximum total dose outside of the intensive care setting is 1mg. The aetiology of the sedative effects should be questioned if there is no response to repeated doses. (c) Flumazenil should not be used in patients with a history of chronic benzodiazepine use. True ?There is an increased risk of seizures in patients with a history of chronic benzodiazepine use. (d) Flumazenil should not be used in patients with a history of chronic TCA use. True ?There is an increased risk of seizures in patients with a history of chronic TCA use. (e) All patients undergoing PSA require continuous O2 monitoring,cardiac monitoring, immediate availability of suction and resuscitation equipment. True ?All patients undergoing PSA require continuous O2 monitoring,cardiac monitoring, immediate availability of suction and resuscitation equipment.


The following are true: (a) Toxic levels of phenytoin occur above 40 umol/L False ?Toxic levels of phenytoin occur above 80 umol/L (b) Toxic levels of theophylline occur above 90umol/L False ?Toxic levels of theophylline occur above 110umol/L (c) Toxic levels of carbamazepine occur above 22 umol/L False ?Toxic levels of carbamazepine occur above 42 umol/L (d) Toxic levels of digoxin occur above 1.5 nmol/L False ?Toxic levels of digoxin occur above 2.6 nmol/L (e) Toxic levels of lithium occur above 1.5 mmol/L True ?Toxic levels of lithium occur above 1.5 mmol/L


The median nerve (a) Supplies adductor pollicis brevis. False Adductor pollicis brevis is supplied by the ulnar nerve (b) Always supplies flexor pollicis brevis. False Flexor pollicis brevis is frequently supplied by the ulnar nerve (c) Reliably supplies sensation to the pulp of the index finger. True (d) Arises from both medial and lateral cords of the brachial plexus. True (e) Is the entraped nerve in carpal tunnel syndrome. True


Lignocaine (a) Has a half life of 2 hours True ?But it has a rapid onset and it is effective for about 30?60 minutes in its plain form (or up to 90 minutes when used with a vasoconstrictor). (b) Maximum safe dose is 3mg/kg True ?70kg man = 210mg. Or 7mg/kg with adrenaline (c) 1% solution is equal to 1mg/ml False ?1% solution is equal to 10mg/ml (d) The max dose for a 70 kg man is 20ml of 1% True ?1% solution contains 10mg/ml so 20 ml's contains 200mg. Max dose is 3mg/kg or 7mg/kg if lignocaine is with adrenaline (e) The maximum dose of 2% for a 70kg man is 10ml True ?2% solution contains 20mg/ml so 10ml's of 2% contains 200mg. The maximum dose in a 70kg man is 3mg/kg(approximately equals to 200mg in total) Peak blood levels of lignocaine usually occur 10?25 minutes after injection. This is the point at which the toxic effects are most likely to be observed. The onset of symptoms is faster if accidental intravascular injection has occurred. The first symptoms and signs of local anaesthetic toxicity are usually neurological with numbness of the mouth and tongue. Shortly afterwards, there is the onset of tinnitus, confusion, seizures, and potentially coma.


Calcium Channel Blocker Toxicity (a) Gut decontamination is recommended True ? (b) Transvenous pacing should be a first line treatment. False ?Calcium is the first line treatment. (c) Insulin/Glucose infusion is recommended. True ?www.toxbase.co.uk (d) Atropine is unlikely to overcome complete heart block. True ? (e) Diarrhoea is a common side effect of verapamil. False Constipation?is a common side effect of verapamil.


The femoral nerve: (a) Lies lateral to the femoral artery. True The femoral nerve lies lateral to the femoral artery. (b) Overlies the iliacus muscle. True The femoral nerve overlies the iliacus muscle. (c) Gives a branch in the thigh to pectineus. True The femoral nerve gives a branch in the thigh to pectineus. (d) The posterior division gives off the medial and intermediate cutaneous nerves of the thigh. False The anterior division of the femoral nerve gives of the medial and intermediate cutaneous nerves of the thigh.


Hypercalcaemia (a) Should be treated with thiazide diuretics to encourage diuresis. False ?Thiazide diuretics should be avoided as they may contribute to hypercalcaemia. (b) Should almost always be treated with a forced saline diuresis eg normal saline 1L 2hourly IV False ?This is potentially hazardous and should only be used when a rapid reduction in plasma calcium is essential(because the patient is comatose or has major cardiac arrhythmias) (c) If plasma calcium is >2.6 mmol/l bisphosphonates should be used to inhibit bone resorption. False ?If plasma calcium is >3.0 mmol/l after rehydration bisphosphonates should be considered to inhibit bone resorption. (d) Forced saline diuresis may cause hypokalaemia. True ?And if forced saline diuresis is to be attempted potassium should be closely watched. (e) Glucocorticoids may have a role in hypercalcaemia due to lymphoma. True ?Also in myeloma, vitamin D toxicity, and sarcoidosis.


Analgesia: (a) Paracetamol has some anti-platelet activity. False ?Hepatotoxicity occurs in doses greater than 140mg/kg/day. (b) Aspirin is not used in children because of its anti-platelet properties. False ?Reye syndrome, is an illness developing during the course of varicella infection in children and presents nausea, vomiting, headache, excitability, delirium, and combativeness with frequent progression to coma. Salicylate use was identified as a major precipitating factor for the development of Reye syndrome and with warnings against the use of aspirin in patients with varicella or influenza this complication has virtually disappeared. (c) Opiates cause muscle rigidity. True ? (d) Opiates can cause urinary retention. True ?Opiates can cause urinary retention, sedation, constipation, respiratory depression and nausea. (e) The onset of effect for morphine is <5 min. False ?The onset of effect for morphine is 5 to 20 minutes and its duration of action is 2 to 6 hours.


Amiodarone can cause: (a) Slate grey skin discoloration. True ? (b) Alopecia. True ? (c) Tremor. True ? (d) Nightmares. True ? (e) Abnormal LFTs in 50% of people. False ?20%.


Adrenaline: (a) Exerts histamine antagonism. True ?Adrenaline exerts histamine antagonism. (b) Increases heart rate, contractility and peripheral vascular resistance. True ?Adrenaline increases heart rate, contractility and peripheral vascular resistance. (c) The dose of adrenaline in cardiac arrest is 1mg IV every 3 to 5 minutes. True ?The dose of adrenaline in cardiac arrest is 1mg IV every 3 to 5 minutes. (d) Patients with anaphylaxis may be given 0.1ml to 0.5ml of 1:1000 dilution intramuscularly. True ?Patients with anaphylaxis may be given 0.1ml to 0.5ml of 1:1000 dilution intramuscularly.Injections into the thigh are more effective at achieving peak blood levels than are injections into the deltoid area.If the patient is refractory to treatment despite repeated intramuscular adrenaline-then an infusion should be started. (e) Adrenaline's onset of effect is 1 to 2 minutes. True ?Adrenaline's onset of effect is 1 to 2 minutes and its duration of of action is 2 to 10 minutes.


The following medications cause enzyme induction (a) Phenytoin True (b) Rifampicin True (c) Carbamazepine True (d) Allopurinol False (e) Sulphonamides False A memory aid for enzyme inducers is PC BRAS...phenytoin,carbamazepine,barbituates,rifampicin,alcohol(chronic abuse) and sulphonylureas(such as gliclazide[diamicron])


Adrenaline side effects: (a) Cardiac arrhythmias. True ? (b) Local tissue necrosis. True ? (c) Pulmonary oedema. True ?Usually in overdose. (d) Cerebral haemorrhage. True ?Usually in overdose. (e) Cold extremities. True ?


Naloxone (a) In the unconscious patient it is appropriate to give naloxone if the respiratory rate is <15 False ?Naloxone should be given if the respiratory rate is <12 or the pupils are pinpoint or there is other reason to suspect opioid poisoning. (b) 800ug IV is an appropriate dose True ?800ug IV is an appropriate dose and can be given every 2-3 mins until the respiratory rate is around 15. (c) The plasma half life of naloxone is longer than that of most opioids False ?The plasma life of naloxone is shorter than that of opioid's and this is why opioid toxic patients given naloxone must be observed for recurrence of the respiratory depression. (d) If there is no response to naloxone then opioid poisoning can be excluded True ?If there is no response to naloxone then opioid poisoning can be excluded (e) Naloxone may cause an increase in blood pressure in normal patients False ?


Regarding ketamine for use for sedation and analgesia (a) It has analgesic, hypnotic and amnesic properties True (b) 500mg is an appropriate oral dose for adults True Also, in severe pain a loading dose of 0.5-1.0mg/kg IM may be given (c) It may precipitate hallucinations True For this reason it is usually administered with a benzodiazepine (d) Ketamine crosses the placenta True Ketamine crosses the placenta and also increases salivation, intracranial pressure and intraocular pressure


Adenosine (a) Is a class III anti-arrhythmic False ?Not classified by vaughan williams (b) Has a negative inotropic effect True ? (c) Has a negative chronotropic effect True ?Slows SA node activity (d) Slows conduction at the AV node True ? (e) Has a long half life False ?2 seconds, making it an ideal drug to stop SVT's


A prolonged QT occurs with: (a) TCA's True A prolonged QT predisposes to torsades de pointes. (b) Sleep True ?Sleep is a cause of prolongation of the QT interval. (c) Sotalol True ?Sotalol, a class III anti-arrhythmic, is a cause of prolongation of the QT interval. (d) Hypothermia True ?Hypothermia is a cause of prolongation of the QT interval. (e) Hypocalcaemia True ?Hypocalcaemia is a cause of prolongation of the QT interval.


With regard to acid-base disturbance... (a) Hypoventilation will cause low PCO2. False (b) Compensation for respiratory acidosis is by retention of H+ ions by the kidney. False (c) Tissue Hypoxia will cause metabolic acidosis. True (d) HCO3 is retained in (respiratory) acidotic states. True (e) Hysteria can cause high PC02. False Hyperventilation causes low PC02 because the patient is 'blowing off' there CO2.Therefore hypoventilation causes high PC02(such as COPD patients).Compensation for respiratory acidosis is by excretion of H+ ions by the kidney with a concurrent retention of HC03. Prolonged tissue hypoxia will cause a metabolic acidosis. Hysteria is associated with hyperventilation and will therfore cause low PC02.


The following drugs can exert their principal effects by enzyme inhibition (a) Pyridostigmine True (b) Atropine False (c) Amlodipine False (d) Digoxin True (e) Selegiline True Pyridostigmine is an inhibitor of acetylcholineesterase used in myasthenia gravis.Atropine blocks muscarinic receptors.Digoxin inhibits Na/K adenosine triphosphatase(ATPase).Selegiline is an MAO-B inhibitor used in Parkinsons disease.


Gelofusine 500mL contains (a) The same amount of sodium per litre as 0.9% saline True Both contain 154 mmol/L of sodium (b) Has a pH of 7.4 True (c) The average gelatine molecular weight is 60,000 False The average molecular weight is 30,000 (d) The osmolarity is 284 mOsm/L False The osmolarity is 274 mOsm/L) years


In retinal detachment Y (a) The retina separates from the retinal pigment epithelium. True (b) Rate of onset is always instantaneous. False the rate of onset is highly variable and infrequently instantaneous (c) A history of flashing lights and ?floaters? is common. True (d) It occurs more commonly in hypermetropes than myopes. False It is more common in myopes, diabetics, the elderly and following trauma


Thrombolysis (a) May be given for up to 12 hours in the context of continuing pain or deteriorating condition. True ?May be given for up to 12 hours in the context of continuing pain or deteriorating condition. (b) Results in a lower earlier CPK rise. False ?Thrombolysis results in a higher earlier CPK rise but a lower total CPK rise. (c) Recanalisation after thrombolysis occurs in 70% True ?Recanalisation without thrombolysis occurs in 15%. (d) Is relatively contraindicated if the patient has had head trauma within 2 weeks. True ?Thrombolysis is contraindicated if the patient has had head trauma within 2 weeks. (e) Is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 6 months. False ?Thrombolysis is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 2 months.


Thrombolysis Y (a) May be given for up to 12 hours in the context of continuing pain or deteriorating condition. True ?May be given for up to 12 hours in the context of continuing pain or deteriorating condition. (b) Results in a lower earlier CPK rise. False ?Thrombolysis results in a higher earlier CPK rise but a lower total CPK rise. (c) Recanalisation after thrombolysis occurs in 70% True ?Recanalisation without thrombolysis occurs in 15%. (d) Is relatively contraindicated if the patient has had head trauma within 2 weeks. True ?Thrombolysis is contraindicated if the patient has had head trauma within 2 weeks. (e) Is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 6 months. False ?Thrombolysis is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 2 months.


When considering a Biers block for regional anaesthesia (a) Raynaud's syndrome is a contraindication True (b) It is commonly used in children False Biers block is rarely used in children and contraindicated below the age of 7 years (c) An appropriate local anaesthetic dose for most adults is 40mL of 1% plain prilocaine False The normal local anaesthetic dose is 40mL of 0.5% prilocaine in adults (d) Requires the presence of at least two members of trained staff True Biers block requires staff competent to deal with severe toxic reactions and have equipment/training to carry out advanced resuscitation


Side effects of typical neuroleptics include (a) Akathisia. True Akathisia is a condition of motor restlessness in which there is a feeling of muscular quivering, an urge to move about constantly and an inability to sit still, a common extrapyramidal side effect of neuroleptic drugs. (b) Intention tremor False Neuroleptic medications cause a resting tremor and rigidity ( a parkinsonian syndrome ). They are not associated with an intention tremor. (c) Tardive dyskinesia. True Tardive Dyskinesia is a syndrome of potentially irreversible, involuntary, dyskinetic movements that may develop in patients who have been treated with antipsychotic medications (for example phenothiazines) longer-term. Other drugs known to cause tardive dyskinesia include: tricyclic antidepressants, selegiline, clozapine, levamisole and metoclopramide. (d) Painless eye rolling movement False (e) Diabetes mellitus False This is a side effect of atypical antipsychotics


Nitrates: (a) Long acting nitrates ( e.g. isosorbide mononitrate ) increase venous return. False ?Long acting nitrates ( e.g. isosorbide mononitrate ) reduce venous return. (b) Long acting nitrates ( e.g. isosorbide mononitrate ) increase diastolic heart pressure. False ?Long acting nitrates ( e.g. isosorbide mononitrate ) reduce diastolic heart pressure. (c) Long acting nitrates ( e.g. isosorbide mononitrate ) increase the impedance to emptying of the left ventricle. False ?Long acting nitrates ( e.g. isosorbide mononitrate ) reduce the impedance to emptying of the left ventricle. (d) Intravenous nitrates should only be given if the systolic blood pressure is over 120mmHg. False ?Intravenous nitrates should only be given if the systolic blood pressure is over 100mmHg. (e) Nitrates reduce pulmonary and dependent oedema. True ?Nitrates reduce pulmonary and dependent oedema by reducing preload and venous pressure.


Adrenaline: (a) Is an Alpha 1 and Alpha 2 agonist. True ?Adrenaline is an Alpha 1 and Alpha 2 agonist and a beta 2 selective agonist. (b) Is more selective for beta 1 than beta 2 receptors. False ?Adrenaline is a beta 2 selective agonist(10 fold over beta 1). (c) Is used as a glaucoma treatment agent. True ?Adrenaline is used as open angle glaucoma treatment. (d) The cardiac arrest dose is 10mg False ?The cardiac arrest dose is 1mg. (e) The anaphylactic reaction dose is 2mg False ?The anaphylactic reaction dose is 0.2-1mg im.


Lignocaine (a) Cimetidine inhibits hepatic metabolism of lignocaine True ? (b) Propranolol inhibits hepatic metabolism of lignocaine True ? (c) Congestive cardiac failure is a contraindication to the use of lignocaine True ? (d) CNS toxic effects may include seizures True ?Also restlessness, tremor and nystagmus (e) Even if a patient is hypersensitive to local anaesthetics they may still receive lignocine IV safely False ?Lignocaine is contraindicated in these circumstances


Potassium Chloride: Y (a) Contraindicated in severe liver impairment. False ? (b) Contraindicated in severe renal impairment. True ? (c) Side effects include nausea True ? (d) Side effects include pvc's. False (e) Side effects include oesophageal ulceration. True ? www.bnf.org Indication for use is potassium depletion. Contraindicated in severe renal impairment, plasma concentrations above 5 mmol/ litre. Side effects include nausea, vomiting,oesophageal or small bowel ulceration.


The following medications are correctly paired with potential side effects (a) Isoniazid-neurotoxicity True ?Prevented by vit B6 (b) Rifampicin-Enzyme Inducer True ?Intracellular activity. Good penetration to most organisms. (c) Ethambutol-Optic neuritis True ?Bacteriostatic.Concentrated in macrophages (d) Pyrazinamide-Gastric Irritation True ?Intracellular activity. Good CSF penetration (e) Para-aminosalicylic acid-gastric irritation True ?Bacteriostatic.Metabolized in liver


Platelet count is commonly raised in (a) Malignancy. True (b) Kawasaki disease. True (c) Megaloblastosis. False Megaloblastosis lowers platelet count (d) Hypersplenism. False Hypersplenism results in pancytopenia


Toxic Medications in Pregnancy: (a) Aminoglycosides can cause neonatal goitre to the fetus. False ?Aminoglycosides can cause vestibular damage to the fetus. (b) Amiodarone can cause vestibular damage. False ?Amiodarone can cause neonatal goitre. (c) ACE inhibitors may cause renal damage and polyhydramnios. False ?ACE inhibitors may cause renal damage and oligohydramnios (d) Retinoic Acid derivatives can cause fetal abnormalities up to a total of 2 months after stopping therapy. False ?Retinoic Acid derivatives can cause fetal abnormalities up to 2 years after stopping therapy. (e) Alcohol can cause fetal growth retardation and a withdrawal syndrome in the newborn. True ?Alcohol can cause fetal growth retardation and a withdrawal syndrome in the newborn


Therapeutic causes of gynaecomastia include: (a) Cimetidine. True Gynaecomastia can be caused by cimetidine. (b) Ranitidine. False (c) Omeprazole. True Gynaecomastia is a side effect of omeprazole according to the BNF. (d) Cannabis. True Gynaecomastia is a side effect of cannabis.


Plain 1% lignocaine (a) Contains 1mg of lignocaine per 1 ml of solution False (b) The safe dose is 7mg/kg in a child False (c) Effect lasts around 30 to 60 min True (d) Risk of toxicity is exacerbated by injection into infective tissue. True (e) Contains adrenaline False 1% lignocaine is equivalent to 10mg/ml.The safe dose in a child is 2-3mg/kg. With adrenaline the safe dose is 7mg/kg.


Midazolam (a) Is a GABA antagonist False ?Benzodiazepines potentiate the effects of GABA. (b) Is pro-convulsant False ?Is anti-convulsant, produces sedation, produces amnesia, produces anxiolysis and respiratory depression. (c) Midazolam's onset of effect is within 5 min True ? (d) Midazolam's duration of action is about 40 min True ?Midazolam's duration of action is about 40 min (e) May cause hypercapnia True ?Through respiratory depression.


Adenosine: (a) It is effective in patients with a heart transplant. True ?Patients post heart transplant are very sensitive to adenosine and you should consider starting at a smaller dose. (b) It is contraindicated in patients with WPW syndrome complicated by A Fib True ?Absolutely ,you risk converting the rhythm to ventricular fibrillation. (c) It should be used with caution in third trimester pregnancy False ? (d) Doses of 36mg may be used in resistant supraventricular tachyarrhythmias True ?If treating a broad complex tachycardia with aberation the diagnosis should be reconsidered before giving these doses. (e) Must be given as a slow push. False ?


Olanzapine (a) Should be used to treat the behavioural symptoms of dementia in elderly patients. False ?Olanzapine ( and risperidone ) are associated with an increased risk of stroke in the elderly. (b) Is a cause of hypotension True ? (c) Is a cause of bradycardia True ? (d) Raises eosinophil count True ? (e) Has less frequent extra-pyrimidal side effects than older typical anti-psychotics. True


Metoprolol (a) Is B2 selective False ?B1 selective (b) The dose is 2.5mg to 5mg IV every 5 to 15 minutes up to a total of 15mg IV True ?Followed by an oral dose of 25mg-50mg 6-8 hourly (c) Can be used safely in decompensated heart failure False ?This is a contraindication for its use (d) Adverse effects include asthma and COPD exacerbation True ? (e) The dose should be halved in compensated heart failure True ?


Morphine (a) Morphine is contraindicated in raised intracranial pressure True ? (b) Morphine use is cautioned in hyperthyroidism False Use is cautioned in Hypothyroidism? (c) Morphine use is safe in renal impairment False Caution should be used in use of morphine in renal impairment- reduce or avoid use. (d) Known side effects of morphine include diarrohea False Constipation is a known side effect. (e) Dry mouth is a known side effect of morphine True ?Side effects of morphine as per BNF 54, nausea, vomitting, constipation, drowsiness, hypotension, respiratory depression, ureteric or biliary spasm, sweating, dry mouth, vertigo facial flushing, bradycardia, tachycardia, palpitations, hallucinations, decreased libido, pruritus and rash. WWW.BNF.ORG.UK


Cefuroxime (a) Has activity against streptococci True ? (b) Has no activity against gram negative organisms False ? (c) Plasma levels should be monitored to avoid toxicity False ? (d) Is principally renally eliminated True ? (e) Has a cross reactivity of 10% for people with hypersensitivity reactions to penicillin True ? Activity is against streptococci, staphylococci, Ecoli and Haemophilus influenza


Substances known to cause SIADH include Yo (a) Tri-cyclic antidepressants True (b) Carbamazepine True (c) Demeclocycline False Demeclocycline is a drug treatment for SIADH (d) Lithium False Lithium causes Diabetes Insipidus


Metformin: (a) Should be used with caution in renal impairment. True ?As patients with renal impairment are at greater risk of developing lactic acidosis. (b) Does not cross into breast milk. False Metformin is excreted into breast milk. (c) Can be used in the treatment of polycystic ovary syndrome. True ?Metformin can be used in the treatment of polycystic ovary syndrome. (d) A known side effect is anorexia. True ?Among the most common side effects are gastrointestinal side effects which include nausea/vomiting (6% to 25%), diarrhea (10% to 53%), and flatulence (12%). Weakness is reported in 9% of patients. (e) A known side effect is ketoacidosis. False Lactis acidosis is a rare side effect- treatment is to be immediately withdrawn if this occurs.Lactic acidosis occurs in <1% of patients on metformin. www.bnf.org


Metformin is contraindicated with (a) Renal impairment True ? (b) Use of iodine containing x ray contrast media True ? (c) Use of general anaesthetic True ? (d) Heart failure False ? (e) Hirsuitism False ? WWW.BNF.ORG


Amiodarone: (a) Does not prolong the QT. False ? (b) It is ineffective in the treatment of supraventricular tachycardias. False ? (c) Has a very large volume of distribution and a wide extent of protein binding. True ? (d) It has class III antiarrhythmic effect because of its Na Channel blocking activities. False ? (e) Most of the active drug is metabolised in the liver by cytochrome p450. True ? Amiodarone is a class III antiarrythmic, but it also has class I, II and IV effects. It is generally well absorbed orally (though this is variable), is highly protein bound, widely distributed with concentration in tissues, undergoes P 450 hepatic metabolism and has a very long half life. Its class III effects are due to blockade of K channels which results in a prolonged action potential (QT) and effective refractory period. It is effective in treating both supraventricular and ventricular tachyarrhythmias, and although it results it has an negative inotropic effect peripheral dilation due to Ca channel blockade means that cardiac output and ejection fraction remain unchanged and it is usually well tolerated hemodynamically. It is administered as slow IV bolus of 150 mg which is repeated after 10 minutes if required. Side-effect with long term use are extensive and include arrhythmias (heart block and TdP) pulmonary fibrosis, hepatic impairment, hypo/hyperthyroidism, skin discoloration and interaction with many cardiac drugs.


Drugs used in nausea and vertigo:

(a) Phenothiazines are dopamine antagonists and act centrally by blocking the chemoreceptor trigger zone. True ?Phenothiazines are dopamine antagonists and act centrally by blocking the chemoreceptor trigger zone. (b) Prochlorperazine is more sedating than chlorpromazine. False ?Prochlorperazine is less sedating than chlorpromazine. (c) Severe dystonic reactions to phenothiazines are less common in children. False ?Severe dystonic reactions are more common in children. (d) Procyclidine may aggravate dystonic reactions caused by metoclopramide. False ?Procyclidine will abort dystonic attacks caused by metoclopramide.


Nitrous Oxide (a) Has a slow onset False ?Has a fast onset and is short acting. (b) Is short acting True ?Has a fast onset and is short acting. (c) The primary adverse effects are nausea and vomiting True ?The primary adverse effects are nausea and vomiting (d) Is safe to use in patient's with head injury. False ?Has sedative properties. (e) Severe pulmonary disease may alter the respiratory elimination of nitrous oxide. True ?It cannot be used in patients with altered mental status, head injury, suspected pneumothorax, or perforated abdominal viscus


The anterior triangle of the neck (a) Is bordered superiorly by the mandible. True (b) Is bordered posteriorly by the posterior border of the sternocleidomastoid muscle. False The anterior triangle is bordered posteriorly by the anterior border of the sternocleidomastoid, the posterior triangle is bordered anteriorly by the posterior border of sternocleidomastoid (c) Contains the submandibular gland. True (d) Contains the inferior belly of the omohyoid. False The inferior belly of the omohyoid is found in the posterior triangle of the neck


Amiodarone (a) Lung toxicity may occur in up to 10% of patients on long term therapy. True ?This is be significant in 3 to 9% of patients (possibly even up to 17%), and may kill the patient if missed. There may be: Interstitial pneumonitis Lung fibrosis Hypersensitivity pneumonitis Bronchiolitis obliterans organising pneumonia (BOOP) has been reported. [ Neth J Med 1998 Sep;53(3):109-12 ] (b) Onset of toxicity may be delayed for 3 months after starting amiodarone False ?Onset of toxicity may be delayed for 3 years after starting amiodarone (c) Neurotoxicity may manifest as proximal myopathy,distal sensory disturbance or peripheral neuropathy. True ?Neurotoxicity has been reported in up to 40%, manifesting mainly as peripheral neuropathy with proximal motor weakness or distal sensory disturbance. Sleep disturbance, ataxia, vivid dreams and fine resting tremor are said to be common, and worse in the elderly. (d) Phototoxicity is common and is a response to UVB. False ?Phototoxicity is common and is a response to UVA. Blue-Grey skin discoloration may occur, as well as itch, petechiae and erythema nodosum. (e) Both hypo and hyperthyroidism may occur. True ?Both hypo and hyperthyroidism may occur.


Sickle cell anaemia (a) Has the genotype HbAS. False HbAS is the genotype for sickle cell trait (HbS is the sickle cell anaemia genotype) (b) Sickle-shaped red blood cells have a life span of only 10-20 days. True Normal red cell lifespan is usually 120 days. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=302592 (c) Is an autosomal dominant disease that results from the substitution of valine for glutamic acid at position 6 of the beta-globin gene. False Sickle cell anaemia is an autosomal recessive condition. (d) Can result in avascular necrosis. True Sickle cell disease can result in avascular necrosis.


Verapamil Hydrochloride: (a) Is contraindicated in second degree AV block. True ?Verapamil is contraindicated in hypotension, bradycardia, second and third degree AV block, sick sinus syndrome, cardiogenic shock, sino-atrial block, history of heart failure or significantly impaired left ventricular function,atrial flutter or fibrillation complicating syndromes associated with accessory conducting pathways e.g Wolff-Parkinson-White), and porphyria. (b) Verapamil injection is indicated directly after beta-blockers for supra-ventricular arrhythmias. False ?Verapamil injection should not be given to patients recently treated with beta blockers because of the risk of hypotension and asystole. (c) Is contraindicated in sick sinus syndrome True ? (d) Grapefruit juice may affect metabolism. True ?Grapefruit juice may affect metabolism of verapamil hydrochloride.


Recognised complications/side effects of local anaesthesia injection with lignocaine include: (a) Depigmentation of dark skin True ? (b) Pain along the distribution of the nerve True ?Withdraw needle and resite it (c) Tinnitus True ?Indicates toxicity (d) Infection True ? (e) Ischaemia and gangrene False ?Only a risk of this if lignocaine used in conjunction with adrenaline to fingers and toes, penis or ears


Amiodarone (a) The volume of distribution of amiodarone is not wide but the half-life is over 50 days. False ?The volume of distribution of amiodarone is large and the half-life is long ( >50 days ) (b) Amiodarone can be given for supraventricular and ventricular arrhythmias and is of particular use in SVT secondary to accessory pathways. True ?Can be given for supraventricular and ventricular arrhythmias and is of particular use in SVT secondary to accessory pathways. (c) A paced individual with third degree AV block may not receive amiodarone. False ?Second and third degree AV block are strong contraindications unless the patient is paced. (d) Both breast feeding and pregnancy are contraindications for amiodarone use. True ?Both breast feeding and pregnancy are contraindications for amiodarone use. (e) There is no interaction between warfarin and amiodarone. False ?There is an erratic interaction. The INR should be closely monitored. www.anaesthetist.com


Ketamine (a) Produces significant respiratory depression. False ?Produces minimal respiratory depression. (b) Is a phencyclidine derivative. True ? (c) Produces amnesia True ? (d) Reduces intracranial pressure False ?Increases intracranial pressure. (e) Produces hypersalivation True ? Adverse effects of ketamine include increased intracranial pressure, increased intraocular pressure, hypersalivation, and reemergence phenomena (disagreeable dreams or hallucinations upon awakening).


Tetanus....... (a) There is a history of injury in 60% of patients. True There is a history of injury in 60% of patients. (b) Outdoor injuries are less at risk than indoor injuries. False Outdoor injuries are more at risk than indoor injuries. (c) Dysphagia is a feature True Dysphagia can be a feature of tetanus. (d) Shorter incubation periods have a better prognosis. False Shorter incubation periods have a worse prognosis. (e) Trismus is a feature. True Trismus can be a feature of tetanus. There is a history of injury in 60% of patients.Outdoor injuries are more at risk than indoor injuries because tetanus is present in soil.Dysphagia, trismus and neck stiffness, back stiffness and abdominal stiffness are common. Generalised spasms with the risk of asphyxiation may develop. Risus sardonicus and opisthotonus(hyperextension of the back and neck due to spasm) may occur. Shorter incubation periods have a poorer prognosis.


Interferons are used in: (a) Hairy cell leukaemia. True ? (b) Kaposi's sarcoma. True ? (c) Renal cell carcinoma. True ? (d) Chronic myeloid leukaemia. True ? (e) CMV encephalitis. False ? Interferons are lymphocyte derived proteins. The 3 types are alpha, beta and gamma.All the above uses use alpha-interferon, B-interferon is used in MS, Gamma -interferon is used as an adjunct to antibiotics to reduce the risk of infection in chronic granulomatous disease.


The following drugs are reversible competitive antagonists: (a) Suxamethonium. False Suxamethonium is an agonist which causes long acting depolarisation. (b) Chlorpheniramine. True Chlorpheniramine is used in perennial and seasonal allergic rhinitis and other allergic symptoms including urticaria. Common side effects include slight to moderate drowsiness. (c) Ranitidine. True (d) Phenoxybenzamine. False (e) Naloxone. True Suxamethonium is an agonist which causes long acting depolarisation.


Salicylate poisoning may present with: (a) Respiratory acidosis. False ?Salicylate poisoning may present with respiratory alkalosis. (b) Metabolic acidosis. True ?Salicylate poisoning may present with metabolic acidosis. (c) Hypokalaemia. True ? (d) Fever. True ?Especially in children. (e) Tinnitus. True ?


In women with recurrent urinary tract infection-and normal renal tracts- appropriate self help measures that can be advised include: (a) Drink cranberry juice daily True A specific type of tannin found only in cranberries and blueberries prevents the adherence of certain pathogens (eg. E. coli) to the epithelium of the urinary bladder. Jepson R, Mihaljevic L, Craig J. "Cranberries for preventing urinary tract infections.". Cochrane Database Syst Rev: CD001321 (b) Empty the bladder before sexual intercourse False After sexual intercourse- even then the evidence is not convincing that this is beneficial in prevention. (c) Vaginal douching False Vaginal douching should not be advised. (d) Drink plenty of coffee. False Drink plenty of water (e) Void regularly and ensure bladder is empty True Practice double micturition


Causes of erythema nodosum include: (a) Sarcoidosis. True Causes of erythema nodosum include sarcoidosis. (b) Herpes simplex. False (c) Ulcerative colitis. True Causes of erythema nodosum include ulcerative colitis. (d) Combined oral contraceptives. True Causes of erythema nodosum include oral contraceptives. Erythema nodosum occurs in bacterial, viral, fungal and protozoal infections as well as inflammatory conditions, malignancies, drugs and pregnancy. Bacterial agents include streptococcus, chlamydia, TB, yersinia, rickettsia, leprosy and leptospirosis. Viral agents include EBV. Fungal agents include histoplasmosis, coccidiomycosis, blastomycosis and protozoal infections include toxoplasmosis. Inflammatory conditions include IBD, sarcoidosis and behcets disease. Malignancies such as lymphoma and leukaemia can also cause EN. Drugs such as sulphonamides, penicillin, the OCP, salicylates and dapsone may cause EN.


Lignocaine: (a) Is in class II of vaughan williams anti-arrhythmic drug classification. False ?Class I, Type B. (b) Reduces the duration of the action potential. True ?Lignocaine reduces the duration of the action potential. (c) Is used to treat supraventricular arrhythmias. False ?Ventricular. (d) May cause nystagmus. True ? (e) Has a high first pass metabolism. True ?


Regional Anaesthesia (a) If the patient reports paraesthesia in the nerve distribution the needle should be removed and re-positioned False ?If the patient reports paraesthesia in the nerve distribution it can be inferred that the proper localisation of the anaesthetic is occurring. (b) 3-5ml's of 1% lignocaine is appropriate for median nerve block. True ?3-5ml's of 1% lignocaine is appropriate for median nerve block. (c) The median nerve provides sensation to the lateral two thirds of the palm of the hand, palmar surfaces of the lateral two and one half digits, and their fingertips False ?The median nerve provides sensation to the lateral two thirds of the palm of the hand, palmar surfaces of the lateral three and one half digits, and their fingertips (d) The palmar branches of the median nerve extend dorsally and supply the dorsum of the little finger False ?The palmar branches of the median nerve extend dorsally and supply the dorsum of the thumb. (e) The median nerve supplies the dorsum of the lateral half of the ring finger distal to the proximal interphalangeal joint and including the nail and the nail bed. True ?The median nerve supplies the dorsum of the lateral half of the ring finger distal to the proximal interphalangeal joint and including the nail and the nail bed.


Local Anaesthetic (a) Bind to calcium channels to cause anaesthesia. False ?The anesthetic action of local anaesthetic is produced when the drug molecules occupy sodium channels within axons to interrupt activity. (b) Local anaesthetics that are more lipid-soluble result in more blockade True ?Local's that are more lipid-soluble more easily penetrate the nerve cell wall and result in more blockade. (c) Addition of adrenaline increases the likelihood of systemic toxicity. False ?Addition of adrenaline decreases the likelihood of systemic toxicity as it slows absorption. (d) Adrenaline increases the pain of the infiltration. True ?Adrenaline increases the pain of the infiltration as it lowers the overall pH of the solution. (e) There is 'anti-dote' for adrenaline accidentaly injected into an end arteriole eg in a fingertip. False ?Topical nitroglycerin paste.


Contraindications to thrombolysis (a) Uncontrolled blood pressure ( >200/120 mmHg) True ?Uncontrolled blood pressure ( >200/120 mmHg) is a contraindication to thrombolysis (b) Pregnancy True ? (c) Recent head trauma within 3 months False ?Recent head trauma within the last 2 weeks is an absolute contraindication to thrombolysis. (d) A history of a proven haemorrhagic stroke or cerebral infarction within the last 2 months. True ?A history of a proven haemorrhagic stroke or cerebral infarction within the last 2 months is an absolute contraindication to thrombolysis. (e) Recent surgery True ?


Entonox (a) Is a gas mixture of 50% nitrous oxide and 50% air False It is a mixture of 50% nitrous oxide and 50% oxygen. It is stored in blue cylinders with a white and blue top (b) Its use is associated with significant hypotension False Entonox produces little physiological change which is why it is a popular and safe method of analgesia for pre-hospital use (c) Is an appropriate method of analgesia soon after scuba diving False While a good method of analgesia for minor procedures and initial pain relief it is not appropriate following diving as entonox will diffuse more rapidly than nitrogen and may therefore increase the risk of decompression sickness (d) Is unsuitable for use in very cold conditions (under -6?C) True The gases may separate at very low temperatures and therefore there is a risk of inadvertent administration of a hypoxic gas mixture


Angiooedema. A 62 year old woman presents with an acutely swollen tongue. Her medications include ramipril. Which of the following statements regarding ACE Inhibitors associated angioedema is/are true. (a) Ace Inhibitors are the most common cause of angiooedema. True ?Ace Inhibitors are the most common cause of angiooedema. (b) The diagnosis is most unlikely if the patient has been on ACE inhibitor therapy for more than 1 month False ?The diagnosis is not unlikely just because the patient has been on ACE inhibitor therapy for more than 1 month. A patient can be on Ace inhibitors for years before developing angiooedema. (c) It is typically limited to the face and oral cavity True ?It is typically limited to the face and oral cavity (d) It is unlikely to progress once treatment has been initiated. True ?It is unlikely to progress once treatment has been initiated. (e) ACE inhibitors are also associated with dry cough. True ?ACE inhibitors are also associated with dry cough. A patient can be on ACE inhibitors for years before developing angiooedema.Treatment consists of stopping the ACE, starting steroids and anti histamines.


The following are true: (a) TCAs cause a 2-4 fold increase in sensitivity to noradrenaline. True ?TCAs cause a 2-4 fold increase in sensitivity to noradrenaline. (b) B2 receptor activation mediates vasodilatation. True ?B2 receptor activation mediates vasodilatation. (c) Noradrenaline has very little activity at B2 receptors. True ?Noradrenaline has very little activity at B2 receptors. (d) Adrenaline has more activity at B2 receptors than at B1 receptors. True ?Adrenaline has more activity at B2 receptors than at B1 receptors.


Tetanus (a) Caused by the endotoxin tetanospasmin False ?Tetanospasmin is an exotoxin. (b) The incubation period is 2-60 days True ?The incubation period is 2-60 days but 90% of cases occur within 15 days. (c) The only treatment is with human tetanus immunoglobulin. False ?The cornerstone of treatment is wound debridement. (d) May produce severe cardiovascular disturbances True ?Tetanus may produce severe cardiovascular disturbances. (e) Produces immunity to those who survive initial infection False ?Those who survive tetanus should receive immunization.


Electrical shock injuries: (a) May result in myoglobinuria and acute renal failure. True Electrical shock injuries may result in myoglobinuria and acute renal failure. (b) Cardiac arrhythmias are more common if only a single limb is involved. False Cardiac arrhythmias occur more commonly when the electrical energy passes transthoracically i.e. from limb to limb through the thorax. (c) Lightning causes a DC shock of very high voltage and short duration. True Lightning causes a DC shock of very high voltage and short duration. (d) Asymptomatic patients with a high voltage conduction injury should be admitted for observation and monitoring. True Asymptomatic patients with a high voltage conduction injury should be admitted for observation and monitoring.


Staphylococcus aureus (a) Is a gram negative bacteria. False Staphylococcus aureus is a gram positive coccus (b) Exotoxin release leads to the toxic shock syndrome. True (c) Is usually sensitive to oral erythromycin. True (d) Causes Scarlet Fever. False Scarlet fever is caused by streptococcal infection


Drug Levels: (a) The therapeutic plasma concentration range for phenytoin is 150-200 umol/L False ?The therapeutic plasma concentration range for phenytoin is 40-80 umol/L (b) The therapeutic plasma concentration range for theophylline is 100-200 umol/L False ?The therapeutic plasma concentration range for theophylline is 55-110 umol/L (c) The therapeutic plasma concentration range for carbamazepine is 42-64 umol/L False ?The therapeutic plasma concentration range for carbamazepine is 21-42 umol/L (d) The therapeutic plasma concentration range for digoxin is 3-5 nmol/L False ?The therapeutic plasma concentration range for digoxin is 1.3-2.6 nmol/L (e) The therapeutic plasma concentration range for lithium is 0.6-1.0 mmol/L True ?The therapeutic plasma concentration range for lithium is 0.6-1.0 mmol/L


Vaughan Williams Classification (a) Digoxin is class IV False ?Cardiac glycosides and adenosine are unclassified (b) Has IV classifications True ?And verapamil is class IV (c) Adenosine is class IV False ?Cardiac glycosides and adenosine are unclassified (d) Amiodarone is class III True ?Along with sotalol, bretylium and disopyramide (e) Beta-Blockers are class II True ?Along with bretylium


Causes of erythema multiforme include (a) Sulphonamides. True (b) Barbiturates. True (c) Benzylpenicillin. False (d) Tuberculosis. True


Warfarin and Other Medications: (a) A patient on warfarin are more likely to have significant bleeding if they are also prescribed cimetidine. True ?A patient on warfarin are more likely to have significant bleeding if they are also prescribed cimetidine. (b) A patient on warfarin are more likely to have significant bleeding if they are also prescribed erythromycin. True ?A patient on warfarin are more likely to have significant bleeding if they are also prescribed erythromycin (c) A patient on warfarin are less likely to have significant bleeding if they are also prescribed ciprofloxacin. False ?A patient on warfarin are more likely to have significant bleeding if they are also prescribed ciprofloxacin (d) A patient on warfarin are more likely to have significant bleeding if they are also prescribed sulphonamides True ?A patient on warfarin are more likely to have significant bleeding if they are also prescribed sulphonamides (e) A patient on warfarin are more likely to have significant bleeding if they are also prescribed thiazide diuretics. True ?A patient on warfarin are more likely to have significant bleeding if they are also prescribed thiazide diuretics.Thiazide diuretics may increase the absorption of blood thinners such as warfarin, leading to an increased risk of bleeding.


Airway Management (a) The normal dose of propofol is 1.5-2.5 mg/kg True ?The normal dose of propofol is 1.5-2.5 mg/kg (b) Propofol may cause involuntary movements on induction. True ?Propofol may cause involuntary movements on induction, other effects include marked hypotension in cardiovascular compromise and pain on injection. (c) The normal dose of ketamine is 1-2 mg/kg for induction. True ?The normal dose of ketamine is 1-2 mg/kg for induction. (d) Ketamine is a bronchoconstrictor and should not be used in asthmatic patients. False ?Ketamine is a bronchodilator. (e) Ketamine causes significant cardiovascular depression. False ?Ketamine causes minimal cardiovascular depression.


Adrenaline: (a) Interacts with quinidine. True ? (b) Interacts with digoxin. True ?Administration of adrenaline and digoxin together increase the likelihood of cardiac dysrhythmias. (c) If used with alpha antagonists are more potent vasopressors. False ?If adrenaline is used with alpha antagonists the vasopressor effect is less potent. (d) Interact with prazosin and doxazosin. True ?Prazosin and doxazosin are alpha blockers and so as mentioned above will make the vasopressor effect of adrenaline less potent. (e) Interact with phenothiazines. True ?Phenothiazines(anti-psychotics) are alpha blockers.


Cardiac Medications: (a) Ca channel blockers and beta blockers potentiate digitalis toxicity. True ?Ca channel blockers and beta blockers potentiate digitalis toxicity. (b) Junctional escape rhythms, 1st degree AV block and premature ventricular beats are associated with digitalis toxicity. True ?Moorman JR, Pritchett EL: The arrhythmias of digitalis intoxication. Arch Intern Med 145:1289, 1985 (c) Patients with digoxin toxicity can complain of seeing blue halo?s around objects. False ?Patients with digoxin toxicity can complain of seeing yellow green halo?s around objects. (d) There is often hypernatremia in patients with acute digoxin toxicity because of Na/K/ATPase pump dysfunction. False ?There is often hyperkalaemia in patients with digoxin toxicity because of Na/K/ATPase pump dysfunction. This is more common in acutely poisoned patients. (e) The clinical presentation of digoxin toxicity may mimic a common illness such as a flu like illness or a gastroenteritis. True ?The clinical presentation of digoxin toxicity may mimic a common illness such as a flu like illness or a gastroenteritis.


The following medications carry an increased risk of rhabdomyolysis: (a) TCAs. True ? (b) Phenothiazines. True ? (c) Benzodiazepines. True ? (d) Paracetamol. False ? (e) Heroin. True ?


The following drugs are agonists (a) Tamoxifen False (b) Salbutamol True (c) Morphine True (d) Cetirizine False (e) Captopril False Tamoxifen is an anti-estrogen used in breast ca. Salbutamol is relatively selective for B2(bronchodilation) but at higher doses can cause B1 effects(tremor and tachycardia).Morphine mimics the endogenous encephalins. Cetirizine is an over the counter anti-histamine(H1-blocker).


Correct therapeutic dosages in paediatric advanced life support are: (a) Adrenaline (epinephrine) = 10mcg/kg. True (b) Atropine = 0.2mg/kg. False 0.02mg/kg is the correct dose of atropine. (c) 10% Calcium chloride = 10-30mg/kg. True (d) Initial fluid bolus = 20ml/kg. True


Amiodarone (a) Is effective in 75% of patients with Atrial Fibrillation True ?Amiodarone is effective in 75% of patients with Atrial Fibrillation. (b) Is useful in patients with non-sustained paroxysmal VT with HOCM or impaired ventricular function True ?Is useful in patients with non-sustained paroxysmal VT with HOCM or impaired ventricular function (c) Has a half life of 2 days False ?The half life of amiodarone is >50days. (d) Amiodarone for IV use should not be made up with 5% dextrose False ?Amiodarone for IV use should be made up with 5% dextrose. (e) Depresses AV nodal conduction True ?Amiodarone depresses AV nodal conduction.


Massive transfusion (a) Hypothermia is a complication. True ?Complications include bleeding, citrate toxicity, and hypothermia. (b) Is the approximate replacement of the patients blood volume within 12 hours. False ?Is the approximate replacement of the patients blood volume within 24 hours. (c) Thrombocytopenia is a result. True ?Thrombocytopenia, platelet dysfunction, DIC, or coagulation factor deficiencies may result in bleeding. (d) Hypercalcaemia is a risk to those who receive more than 5U of whole blood. False ?Hypocalcaemia is a risk in those who receive more than 5U of whole blood, those with liver disease, and neonates from citrate toxicity. (e) Citrate toxicity may cause platelet dysfunction. False ?Citrate toxicity may cause hypocalcaemia.


The anti malarial drug mefloquine: (a) Is an appropriate drug of choice where there is a substantial risk of chloroquine resistant falciparum malaria. True ?Mainly for sub-Saharan Africa and some areas of South Africa (b) Normal dose is 250mg daily False ?250mg weekly (c) Must never be taken in pregnancy False ?May be taken in second and third trimesters (d) Recognised side effects include hallucinations True ?And other neuro-psychiatric side effects affect 0.01 per cent or more of people (e) Is probably best started three weeks before departure. True ?Most side effects develop in first three weeks, so gives time to change drug if necessary


Oral Tetracyclines (a) May aggravate pre-existing renal failure True May aggravate pre-existing renal failure (b) Should be taken with meals False They should be taken 1 hour before or two hours after meals as food can interfere with there absorption. (c) If given to children under the age of 8 may cause permanent discoloration of teeth True If given to children under the age of 8 may cause permanent discoloration of teeth (d) Primary indications include the treatment of brucellosis True Primary indications include brucellosis,chlamydia, mycoplasma and rickettsial infections (e) May form insoluble complexes in the gut lumen with antacids True They may bind with antacids and not be absorbed. Tetracyclines inhibit protein synthesis which increases azotaemia. They should be taken 1 hour before or two hours after meals as food can interfere with there absorption.They can also cause dental enamel hypoplasia in infants.Primary indications include brucellosis,chlamydia, mycoplasma and rickettsial infections.They may bind with antacids and not be absorbed.


Amiodarone: (a) Is a class I anti-arrhythmic agent. False ?Amiodarone is a class III anti-arrhythmic agent. (b) Amiodarone prolongs the action potential in the atrium. True ?Amiodarone prolongs the action potential in the atrium and the ventricle. (c) Prolongs the action potential in the ventricle. True ?Amiodarone prolongs the action potential in the atrium and the ventricle. (d) Amiodarone depresses the AV node. True ?Depression of the AV node seems to be its major effect in acute use. (e) Causes an increase potassium uptake in the region of the SA node. False ?


Dobutamine (a) Has a significant vasopressor effect False ?The alpha 1 agonism effect of dobutamine is offset by the alpha 2 agonism effect. (b) Has a significant inotropic effect True ?Through Beta 1 and Beta 2 agonism (c) Decreases peripheral vascular resistance True ?And increase cardiac output (d) In higher doses can increase heart rate True ? (e) Adverse effects can include hypotension True ?From skeletal muscle bed vasodilation, tachycardia, ectopy, headache and paresthesias


Thiazide Diuretics (a) Inhibit sodium reabsorption at the beginning of the proximal convoluted tubule. False ?Thiazide Diuretics inhibit sodium reabsorption at the beginning of the distal convoluted tubule. (b) They act within 1-2 hours of ingestion. True ?They act within 1-2 hours of ingestion and most have a duration of action of 12-24 hours. (c) May cause hyperkalaemia False ?Thiazides cause hypokalaemia. (d) Thiazide diuretics can cause impotence. True ?This is revesible on withdrawal of medication. (e) Are associated with gout. True ?Thiazide diuretics are associated with gout.


Ketamine: (a) Ketamine is not safe to give to asthmatics False ?Ketamine is a bronchodilator and is safe to give to asthmatics (b) Hallucinations are a greater problem in paediatric practice than in adult practice. False ?Hallucinations is a greater problem in adult practice than in paediatric practice (c) Causes tachycardia and hypertension True ?Ketamine is a stimulator of the cardiovascular system and causes tachycardia and hypertension (d) The paediatric dose for minor procedures is 5mg/kg IM False ?The paediatric dose for minor procedures is 2-2.5mg/kg IM (e) The adult IV dose is 1.5mg/kg True ?The adult IV dose is 1.5mg/kg


The Brown-Sequard Syndrome (a) Is the result of spinal cord hemisection. True The brown sequard syndrome is the result of spinal cord hemisection. It is a rare syndrome, consisting of ipsilateral hemiplegia with contralateral pain and temperature sensation deficits because of the crossing of the fibers of the spinothalamic tract.

(b) Occurs more commonly in closed rather than in penetrating injury. False Brown-Sequard syndrome is a seldom encountered syndrome, usually the result of penetrating trauma to the cervical or thoracic spine. It is now also associated rarely with herniated cervical disks. (c) Results in contralateral paralysis below the injury. False It consists of ipsilateral hemiplegia with contralateral pain and temperature sensation deficits because of the crossing of the fibers of the spinothalamic tract. (d) Results in contralateral temperature sensory loss. True As a result of the interruption of the lateral spinothalamic tract. (e) Results in ipsilateral vibration and proprioception loss. True As a result of interruption of the posterior column.


Tetanus... (a) Has a mortality rate of 10% False (b) Is common in the UK and Ireland. False (c) Clostridium tetani produces an exotoxin which is neurotoxic. True (d) It is rapidly eliminated by the kidneys which limits is toxicity. False (e) It enters the spinal cord via the CSF. False Tetanus has a mortality rate of 60% and is rare in the UK and Ireland but common in other parts of the world.Clostridium tetani produces an exotoxin which is neurotoxic.It is poorly eliminated from the blood by the kidneys and enters the spinal cord by way of the peripheral nerves.


Airway Management (a) Suxamethonium (Succinylcholine) is a non-depolarising neuromuscular blocker. False ?Suxamethonium (Succinylcholine) is a depolarising (non-competitive) neuromuscular blocker which produces profound paralysis within 30-45 seconds of an intravenous injection of 1.5-2 mg/kg. (b) The normal dose of suxamethonium (succinylcholine) is 10-20 mg/kg. False ?The normal dose of suxamethonium (succinylcholine) is 1.5-2 mg/kg. (c) Suxamethonium is associated with bradycardia. True ?Suxamethonium is associated with bradycardia especially in children who are particularly sensitive to the muscarinic effects of suxamethonium. (d) Ketamine is a bronchodilator True ?Ketamine is a bronchodilator. The normal induction dose is 1-2mg/kg, the onset of anaesthesia is 15-30 seconds, the recovery time is 15-30 minutes and it has minimal cardiovascular depression. (e) Propofol is not associated with cardiovascular depression. False ?Propofol is associated with cardiovascular depression, pain on injection and involuntary movements on induction.


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Appropriate pharmacological management of an acutely agitated 70 year old man with no history of mental illness may include: (a) Haloperidol 5mg False ?Caution must be exercised with use of antipsychotics in the elderly ( >65). Recommended dosing for this age group is 0.5- 1.5mg po/ im. (b) Olanzapine 2.5 mg False There is a warning out re the use of Olanzapine and Risperidone in patients over the age of 65. The is an increased risk of cerebrovascular accident. (c) Risperdone 1mg False ? (d) Lorazepam 0.5mg True ? (e) Chlorpromazine 25mg True ? www.bnf.org

(a) Established pregnancy. True (b) History of ectopic pregnancy. False past history of ectopic pregnancy is a relative not absolute contraindication (c) Concurrent use of antiepileptic medications. False enzyme inducing drugs are not a contraindication to Levonelle, however the dose given should be increased to take this into account (usually doubled in most cases) (d) History of porphyria. True

The following are true: (a) The anti-coagulant effect of warfarin is enhanced by allopurinol. True ?The anti-coagulant effect of warfarin is enhanced by allopurinol. (b) The anti-coagulant effect of warfarin is reduced by the concomitant use of anabolic steroids. False ?The anti-coagulant effect of warfarin is enhanced by the concomitant use of anabolic steroids. (c) The anti-coagulant effect of warfarin is enhanced by the concomitant use of metronidazole. True ?The anti-coagulant effect of warfarin is enhanced by the concomitant use of metronidazole. (d) The anti-coagulant effect of warfarin is reduced by the concomitant use of erythromycin. False ?The anti-coagulant effect of warfarin is enhanced by the concomitant use of erythromycin.

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Pharmacodynamics is the study of the effects of drugs on biological processes. One of the pharmacodynamic effects of morphine is pupil constriction


Antibody molecules (a) Consist of two identical light chains and two identical heavy chains. True (b) There are five major types of light chain (m, g, a, e and d). False There are two light chains, k and l. (c) Are produced as integral membrane proteins of T cells. False B cells (d) IgA is the most abundant immunoglobulin class in secretions. True


If renal function is normal it's half life is 2 hours.


?Tetanus prone? wounds (a) Include puncture wounds and those more than 6 hours old. True (b) Always require HATI treatment even if tetanus immunisation cover is adequate. False (c) HATI and TTB can both be given into the same limb. False Tetanus vaccine and immunoglobulin must be given by separate syringes into separate sites (d) Pregnancy is a contraindication to tetanus prophylaxis. False

Drugs that should be avoided in renal impairment Y (a) Nalidixic Acid True ?Should be avoided. (b) Tetracycline True ?Should be avoided. (c) Vancomycin False ? (d) Erythromycin False ? (e) Ampicillin False

The following toxic substances are correctly matched with their antidotes (a) B-blockers????..Glucagon. True (b) Ethylene Glycol??Dicobalt edetate. False Ethanol is used in ethylene glycol poisoning (dicobalt edetate is used in cyanide poisoning) (c) Iron salts?????.Desferrioxamine. True (d) Paracetamol???..Methionine. True Methionine is administered orally (NAC is used commonly and is given IV)


Plain 1% lignocaine

(a) Contains 1mg of lignocaine per 1ml of solution. False 1% is equivalent to 10mg per mL. (b) The safe dose is 7mg/kg in a child. False 2-3 mL/kg (7mL/kg is the safe dose of lignocaine with adrenaline). (c) Effects last around 120 minutes. False Effects of 1% lignocaine last around 30-60 minutes. (d) Risk of toxicity is increased by injection into infected tissues. True Risk of toxicity with lignocaine is increased by injection into infected tissues.

MCEM MCQ Pharmacology

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