MRCP part 1-pharm guestions

Question: 1 of 100 / Overall score: 100% A 70-year-old man presented with increasing dyspnoea. In his history, he had suffered a myocardial infarction two years previously which had been complicated by ventricular arrhythmias. At admission his oxygen saturations were 85% on air and a chest X-ray revealed bilateral patchy infiltration of both lung fields with a cardiothoracic ratio of 20/30 cm. Which of the following drugs that he has been prescribed is most likely to explain these findings? (Please select an option) Amiodarone Correct Atorvastatin Aspirin Furosemide Ramipril This patient has desaturation with patchy infiltration on CXR suggesting a diagnosis of amiodarone-induced lung disease. Usually the presentation is insidious and the disorder associated with the cumulative dose. Treatment depends on withdrawing amiodarone and initiation of steroid therapy. Differential diagnosis is any lymphangitis/pnemonitis but High resolution CT can help by demonstration of radio-dense plaques etc. Question: 2 of 100 / Overall score: 100% Imidazoline receptors True / False are found in the medulla Correct stimulation leads to increased sympathetic activity Correct stimulation leads to reduced arterial blood pressure Correct stimulation leads to increased excretion of sodium and water Correct have a physiological role in haemorrhagic shock Correct a-also kidneys and adrenal b-stimulation leads to decreased central and peripheral sympathetic activity c-this is the action of the antihypertensive drug moxonidine d-the action of I1 receptors in the kidney e-no physiological role identified nor any natural endogenous ligand has been found. They may somehow be involved in the 'metabolic syndrome' - hyperglycaemia, hyperlipidaemia and insulin resistance. (Drugs and Therapeutics Bulletin 1997;35(5):33-36 and Lancet Jan 17. 1998) Question: 3 of 100 / Overall score: 87% The following are features of poisoning with organo-phosphorous insecticides True / False the effects may follow eating contaminated fruit Correct the acute symptoms and signs are due to widespread cytotoxic damage in the nervous system Incorrect answer selected incontinence of urine or faeces is an early manifestation Correct flaccid paralysis of the limbs may occur some weeks after exposure Correct the use of penicillamine reduces structural damage and leads to gradual recovery Incorrect answer selected causes irreversible inhibition of acetylcholinesterase, Rx with antimuscarinics

Question: 4 of 100 / Overall score: 65% Lead poisoning: (Please select an option) Causes adrenal suppression Can only result from lead ingestion Incorrect answer selected Is associated with a macrocytic anaemia Causes a peripheral neuropathy due to demyelination This is the correct answer Commonly presents with diarrhoea Lead can also be absorbed through the skin and by inhalation. Associated with iron deficiency & a microcytic anaemia. Most common GI symptoms are abdominal colic and constipation. Question: 5 of 100 / Overall score: 64% Recognised causes of methaemoglobinaemia include: True / False dapsone Correct isoniazid Correct lidocaine Incorrect answer selected isobutyl nitrite Incorrect answer selected cotrimoxazole Correct b – isoniazid causes peripheral neuropathy, hepatitis and drug-induced lupus. It is metabolised by acetylation and in 'slow acetylators' there is an increased risk of neuropathy but a decreased risk of hepatitis and lupus. c,d,e – Causes of methaemoglobinaemia include hereditary haemoglobinopathies, nitrites / nitrates, analine dyes, phenacetin, sulphonamides, chlorates, lidocaine, heavy metals Question: 6 of 100 / Overall score: 53% A 25-year-old male homosexual is admitted with dyspnoea and weight loss of 2 months duration. He is diagnosed with Pneumocystis pneumoniae due to AIDS. Which of the following concerning Pneumocystis pneumonia is true? (Please select an option) May have an extra pulmonary presentation This is the correct answer It is always associated with X-ray changes Incorrect answer selected It is caused by a bacterium Elevated serum antibodies to P. carinii are helpful diagnostically It is best treated with intravenous pentamidine a-Any HIV associated condition. b-5-15% have normal CXR (always is always false ... but not always!). c-A fungus. d-There is polyclonal B-cell activation in AIDS. eintravenous cotrimoxazole. (Dr Shu Ho) Question: 7 of 100 / Overall score: 49% Gabapentin

True / False is a potent hepatic enzyme inducer Correct side effects typically include visual field defects with long-term use Incorrect answer selected therapy is best monitored through measuring plasma concentrations Incorrect answer selected is of particular value as monotherapy in absence attacks (petit mal) Incorrect answer selected requires dose adjustment in renal disease Incorrect answer selected Gabapentin does not induce cytochrome P450 unlike other anticonvulsants such as phenytoin and phenobarbitone. Vigabatrin may cause visual field defects, which may be irreversible. Rarely have visual disturbances been associated with gabapentin. No use in Petit Mal and is used for add-on therapy in partial or generalised seizures. Question: 8 of 100 / Overall score: 45% The following drugs can safely be given together True / False indomethacin and enalapril Incorrect answer selected adrenaline and amitriptyline Correct aspirin and phenobarbitone Incorrect answer selected oral contraceptives and kaolin Incorrect answer selected ranitidine and warfarin Incorrect answer selected 1st stem: constriction of afferent glomerular arteriole (indomethacin) + dilatation of efferent arteriole (ACE I) leads to decreased GFR. 4th stem: no interaction mentioned in BNF. Question: 9 of 100 / Overall score: 47% Amiodarone: True / False decreases the sensitivity of the pituitary to T4 and T3 Incorrect answer selected inhibits TSH release Incorrect answer selected inhibits thyroid hormone synthesis Correct reduces peripheral conversion of T4 to T3 Correct contains iodine Correct No wonder it interferes with thyroid function! Amiodarone can cause hyper or hypothyroidism. Question: 10 of 100 / Overall score: 42% A 40-year-old ex-footballer presents requesting treatment for alcoholism and is prescribed disulfiram. What is the mode of action of disulfiram? (Please select an option) Decreases severity of alcohol withdrawal Incorrect answer selected

Helps alcoholics to drink safely Inhibits acetaldehyde dehydrogenase activity This is the correct answer Inhibits alcohol dehydrogenase activity Reduces the desire for alcohol Alcohol is mainly metabolised in the liver to acetaldehyde by alcohol dehydrogenase. Acetaldehyde is then oxidised to acetate by acetaldehyde dehydrogenase (AcDH). Disulfiram irreversibly inhibits the oxidation of acetaldehyde by competing with the cofactor nicotinamide adenine dinucleotide (NAD) for binding sites on AcDH. The increased acetaldehyde levels are thought to produce the unpleasant side effects associated with acetaldehyde syndrome such as headaches, nausea, flushing etcetera. Question: 11 of 100 / Overall score: 38% Isotretinoin is associated with True / False teratogenicity in pregnancy This is the correct answer dry nasal mucosa This is the correct answer increased serum triglycerides This is the correct answer gynaecomastia This is the correct answer benign intracranial hypertension This is the correct answer a-important teratogenic risk b-dry skin and mucosal surfaces c-and cholesterol d-but may cause hair thinning or hirsutism e-and cataracts, corneal opacities, headaches, drowsiness, thrombocytopenia, anaemia and so many other things it is a natural attractor for exams Question: 12 of 100 / Overall score: 35% An 18-year-old female presents 12 weeks into an unplanned pregnancy. She had been diagnosed with epilepsy six years ago which was well controlled on sodium valproate and had been taking the combined oral contraceptive pill (OCP) for three years. Which of the following is correct concerning this patient? (Please select an option) Lamotrigine should be substituted for sodium valproate She should be advised to have a termination of her pregnancy. Incorrect answer selected Sodium valproate interaction with the oral contraceptive increased the risk of pregnancy. The dose of sodium valproate should be increased. There is an increased risk of a neural tube defect in her fetus. This is the correct answer This patient has become pregnant on valproate. This therapy has controlled her seizures and should not be changed now. However, there is an increased risk of neural tube defects associated with valproate and this could be reduced by folate therapy. Valproate is not an enzyme inducer and unlike other anticonvulsants would not speed up metabolism of the OCP.

It is entirely up to the individual if they wish to pursue the pregnancy or not. Question: 13 of 100 / Overall score: 32% A 36-year-old female presents with a six month history of having problems sleeping at night. She has been woken on numerous occasions by her legs which are irritable and feel that they are being tugged. She needs to keep moving them. This urge lasts for variable periods and she finds little relief from rubbing the legs. No abnormalities are noted on examination of her legs. Which of the following is the most appropriate treatment for this patient? (Please select an option) Amitriptyline Incorrect answer selected Gabapentin Psychiatric referral Ropinirole This is the correct answer Venlafaxine This patient has features of restless legs syndrome (RLS). Typically there is an uncomfortable sensation in the legs and a feeling of needing to move them. The exact aetiology is unknown. Although no specific tests exist for the diagnosis it is based on the International Restless Legs Syndrome Study Group four basic criteria for diagnosing RLS: (1) a desire to move the limbs, often associated with paresthesias or dysesthesias (2) symptoms that are worse or present only during rest and are partially or temporarily relieved by activity (3) motor restlessness, and (4) nocturnal worsening of symptoms. Treatment depends on the severity of the problem and the most appropriate treatment here would be ropinirole, which is the only agent licensed for this purpose. Question: 14 of 100 / Overall score: 34% The causes of SIADH include: True / False empyema Incorrect answer selected subdural haematoma Correct chlorpropamide Incorrect answer selected desmethylchlortetracycline Correct hyperthyroidism Correct c-And carbamazepine, phenothiazines, tricyclics, syntocin. d-Used in the treatment. eHypothryroidism. (Dr Mick Bialas) Question: 15 of 100 / Overall score: 35% The following diuretics are correctly linked with their site of action: True / False Furosemide and thick ascending limb of the loop of Henle Correct

Bendroflumethiazide and the proximal tubule Incorrect answer selected Mannitol and the descending limb of the loop of Henle Incorrect answer selected Metolazone and the early distal tubule Correct Spironolactone and the cortical collecting tubule Incorrect answer selected Thiazides of which metolazone and bendroflumethiazide are examples, inhibit sodium reabsorption at the distal convoluted tubule. Loop diuretics inhibit reabsorption from the ascending limb of the loop of Henle. Spironolactone antagonises the effect of aldosterone on the distal convoluted tubule. Mannitol is an osmotic diuretic and works primarily on the proximal convoluted tubule. Question: 16 of 100 / Overall score: 34% Nephrogenic diabetes inspipdus: True / False has autosomal recessive inheritance Incorrect answer selected can be associated with sickle cell anaemia Incorrect answer selected serum vasopressin levels are normal or low Incorrect answer selected can be caused by hypercalcaemia Correct responds to treatment with thiazides Incorrect answer selected a-X-linked, c-normal or high. (Dr Mick Bialas) Question: 17 of 100 / Overall score: 32% Which of the following drugs is most likely to cause systemic lupus-like syndrome? (Please select an option) Baclofen Isoniazid Methotrexate Procainamide This is the correct answer Sulphasalazine Incorrect answer selected A recessive gene is responsible for the activity of hepatic N-acetyl transferase resulting in slow or fast (intermediate and fast groups get lumped together) acetylation. 45% of the United Kingdom population are slow acetylators. • Drugs affected include: • • • • • • • • •

isoniazid hydralazine dapsone procainamide and sulphasalazine. Slow acetylators have increased risk of isoniazid-induced peripheral neuropathy, and hydralazine or procainamide-induced systemic lupus erythematosus (SLE).

Fast acetylators were considered more at risk of isoniazid-induced hepatitis but this is not bourne out by the recent evidence. Question: 18 of 100 / Overall score: 36% A 65-year-old African man with a known history of hypertension presents with ankle oedema after taking an antihypertensive prescribed by his general practitioner. He is now found to have a blood pressure of 160/100 mmHg. Which of the following would be the preferred drug for this patient? (Please select an option) Amlodipine Atenolol Bendroflumethiazide Correct Ramipril Verapamil The patient has ankle oedema which is usually due to vasodilatation by calcium channel blockers. The preferred initial antihypertensive therapy for the elderly African patient will be bendrofluthiazide according to BHS guideline, 2004. Angiotensin-converting enzyme (ACE) inhibitors are preferred for those patients with heart failure or diabetic nephropathy. ß-blockers are preferred for post-myocardial infarction and ischaemic heart disease. Question: 19 of 100 / Overall score: 38% A 40-year-old man presents with unsteadiness of gait and bilateral gynaecomastia. These two features can be explained by True / False Klinefelter's syndrome Correct long-term therapy with phenytoin Correct carcinoma of the lung Correct long term corticosteroid therapy Incorrect answer selected chronic alcohol abuse Correct Phenytoin may cause both ataxia and gynaecomastia. Other causes would include alcohol and lung cancer (associated with paraneoplastic cerebral atrophy) Question: 20 of 100 / Overall score: 36% A 50-year-old man with hypertension already on furosemide, ramipril and digoxin is found to have poor left ventricular function on echocardiogram. Which antihypertensive should be added? (Please select an option) Carvedilol This is the correct answer Diltiazem Incorrect answer selected Doxazosin Hydralazine Nifedipine •

This patient has hypertension and reduced ejection fraction (EF) on echo indicating an element of failure. In these circumstances the most appropriate agent with evidence to support its use for reducing morbidity and mortality in failure would be the addition of a beta blocker. Question: 21 of 100 / Overall score: 39% An 18 year-old girl receives radioactive iodine as treatment of thyrotoxicosis. Which of the following is the most likely long-term complication of this treatment? (Please select an option) hypoparathyroidism hypothyroidism Correct increased risk of developing cancer recurrent laryngeal nerve damage osteoporosis RAI is safe and that is why it is given across all ages as a definitive treatment of thyroxicosis. The most likely side effect of radioactive iodine is hypothyroidism with approx 80% developing hypothyroidism after therapy. There is no evidence to suggest that RAI is associated with any cancers. However, RAI must not be given to pregnant females particularly after the 12th gestational week as it would be taken up by the developing foetal thyroid causing fetal hypothyroidism and is also considered to be teratogenic. Recurrent laryngeal nerve damage is a potential risk of thyroid surgery, not RAI. Question: 22 of 100 / Overall score: 41% Baclofen True / False derived from GABA Correct causes rhabdomyolysis Correct reduces cerebral but not spinal spasticity Correct cause hallucinations when withdrawn Correct reduce Ca2+ release from sarcoplasmic reticulum Incorrect answer selected Primary site of action = spinal cord, by depressing monosynaptic and polysynaptic transmission. It can hyperpolarise cells by increasing K+ conductance and inhibit Ca2+ channels in others. Rhabdomyolysis caused by clofibrate, aminocaproic acid, HMGCoA reductase inhibitors and neuroleptics (neuroleptic malignant syndrome). Question: 23 of 100 / Overall score: 43% A 17-year-old woman underwent a renal transplant. She was concerned about the effects of long-term ciclosporin treatment. Which one of the following is a common adverse effect of this drug? (Please select an option) Alopecia Bone marrow depression Hepatotoxicity Nephrotoxicity Correct

Paraesthesia Ciclosporin causes hypertrichosis rather than alopecia and the most frequent adverse side effect of this drug is nephrotoxicity. Post renal transplant, the two most common causes of declining renal function are graft rejection and ciclosporin toxicity. Hepatototoxicity and parasthesia are less common side effects of the drug. Question: 24 of 100 / Overall score: 42% A 17-year-old female presents to the emergency department following self-confessed paracetamol poisoning after discovering she is eight weeks pregnant and had a row with her boyfriend. She claims to have taken an approximately 30 paracetamol tablets approximately 58 hours ago. Her history is considered to be reliable. There are no abnormalities to find on examination. Her blood sugar by finger prick testing was 3.1 mmol/l. Which of the following would be the most appropriate treatment for this patient? (Please select an option) Haemodialysis Intravenous dextrose infusion Incorrect answer selected Intravenous N-acetylcysteine This is the correct answer Oral activated charcoal Oral vitamin K Irrespective of the pregnancy, this girl should receive n-acetyl cysteine. Paracetamol concentration is unhelpful in delayed presentation of paracetamol overdose. A dose of more than150mg/kg is considered to be toxic and toxicity occurs at a lower concentration if the patient is thought to be in high risk group. Clotting screen international normalised ratio (INR), liver function tests, acid-base balance and plasma glucose should be taken without delay prior to starting treatment with N-acetylcysteine. Serial monitoring of clotting screen is required and N-acetylcysteine should continue until INR returns to normal. Further advice on treatment of complicated cases should be sought from National Poisons Information Service. Other supportive treatment is guided by the patient's condition. Question: 25 of 100 / Overall score: 40% A 58-year-old woman presents with early features of COPD. She is a heavy smoker and asks about drugs that may help her to stop smoking. In particular, she has heard about a new drug that is now available called Champix (varenicline). Varenicline is an agent used in the treatment of smokers to help them quit. Which of the following best describes its mechanism of action? (Please select an option) An a2-noradrenergic agonist that suppresses sympathetic activity Is a nicotine replacement therapy Incorrect answer selected Is a partial agonist of the alpha4beta2 nicotinic receptor This is the correct answer A tricyclic antidepressant with mostly noradrenergic properties

Reduces uptake of dopamine, serotonin and norepinephrine There are now many therapies that have been investigated for use in smoking cessation. Newer drugs are becoming available that have been sepecifically developed for smoking cessation. Varenicline is one of them. Nicotine is a simulant and releases dopamine in the brain that leads to addictive effects of smoking. Its effects can be replaced in other ways using nicotine replacement therapy and this reduces the addiction to cigarrette smoking. Bupropion (Zyban) reduces the neuronal uptake of dopamine, serotonin and norepinephrine. Clonidine, a second line agent in smoking cessation because of its side effects, is an a2-noradrenergic agonist that suppresses sympathetic activity. Nortriptyline is a tricyclic antidepressant with mostly noradrenergic properties and is an agent that appears to be effective. Varenicline is a nonnicotine drug that is a partial agonist of the alpha4beta2 nicotinic receptor. Further reading: Int J Clin Pract. 2006 May;60(5):571-6 (Review) JAMA. 2006 Jul 5;296(1):47-55 (trial vs. bupropion and placebo) Royal College of Physicians publication on smoking cessation Other news articles on Varenicline Question: 26 of 100 / Overall score: 40% Dopa-decarboxylase inhibitors True / False enhance the effect of levodopa on the substantia nigra Incorrect answer selected reduce the extracerebral complications of L-dopa therapy Correct have anticholinergic activity Correct should not be given in combination with dopamine agonists Incorrect answer selected prevent L-dopa associated dyskinesias Incorrect answer selected A – Dopa-decarboxylase inhibitors prevent the systemic metabolism of levodopa which leads to higher CNS levels. The effect itself is not enhanced only the concentration of available levodopa. B – these include nausea, vomiting, postural hypotension and cardiac arrhythmias. D – the combination makes dyskinetic movements more likely E - No. Dyskinesias are a CNS effect of levodopa. Question: 27 of 100 / Overall score: 40% The following statements about growth hormone are true: True / False arginine is a potent inhibitor of growth hormone release Incorrect answer selected hypoglycaemia is a potent growth hormone stimulus Correct growth hormone has a dual hypothalamic regulation Incorrect answer selected increased levels can lead to enlargement of the liver Incorrect answer selected bromocriptine can suppress growth hormone release Correct e-?paradoxically in acromegaly - keyword 'can'. (Dr Mick Bialas) Question: 28 of 100 / Overall score: 39%

A 29-year-old woman is receiving subcutaneous Clexane (low-molecular weight heparin [LMWH]) for the treatment of pulmonary embolism. She is 30 weeks pregnant and develops bruising on her lower arms. The blood pressure in the left lateral position is 125/75 mmHg. What is the most appropriate test for this patient? (Please select an option) Anti factor Xa levels Incorrect answer selected APTT Platelet count This is the correct answer Serum albumin Serum potassium This is likely to be heparin-induced thrombocytopaenia (HIT). Long-term LMWH treatment has been associated with low platelet counts and this is the test which is likely to provide you with the most information. Clexane may cause hyperkalaemia, but this is unlikely to cause bruisisng. Albumin levels may increase in pregnancy but serum albumin may be low due to haemodilution. Activated partial thromboplastin time (APTT) is not of use in monitoring LMWH activity, although APTT may be prolonged in high dose Clexane treatment. Factor Xa levels can be used to monitor efficacy of treatment but the suggestion of brusing here points more to HIT for which Xa levels would not be a useful guide. Question: 29 of 100 / Overall score: 41% A 70-year-old female who is receiving amiodarone for paroxysmal atrial fibrillation presents with tiredness and weight loss. Investigations reveal: C-reactive protein 6 mg/L (