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The London and Essex PSA Masterclass Day Practice Paper Friday 24/01/2024 Clinical Teaching Fellows Southend University Hospital Mid and South Essex NHS Foundation Trust mse.suh.clinicalteachingfellows@nhs.netPRESCRIBING A68-year-old male patient presents to the emergency department with increasing shortness of breath, a productive cough with green sputum, and wheezing. He has a known history of Chronic Obstructive Pulmonary Disease (COPD) and takes a tiotropium inhaler once daily. He is a current smoker with a 40-pack-year smoking history. He reports that his symptoms have progressively worsened over the past 2 days, and he has used his salbutamol inhaler more frequently with little relief. Drug History: • Tiotropium, 5 mcg once daily, via inhalation • Salbutamol, 100 mcg as needed, via inhalation • No known drug allergies On Examination: • Respiratory rate: 24 breaths per minute • Oxygen saturation: 88% on room air • Use of accessory muscles to breathe • Auscultation reveals widespread wheezes and reduced air entry Investigations: • Arterial blood gas shows: PaO2 7.8 kPa, PaCO2 6.5 kPa, pH 7.35. • Chest X-ray shows hyperinflated lungs with no signs of pneumonia. QUESTION 1Write a prescription for ONE drug that is most appropriate to relieve this patient’s bronchospasm. PRESCRIPTION FORM MEDICINE Salbutamol DOSE ROUTE 2.5 – 5mg INH/NEB FREQUENCY DURATION QDS Continuous PRESCRIBER DATE Dr A Aaronson XX/XX/XXXX A48-year-old female has been admitted to the acute medical unit with a diagnosis of acute pancreatitis. She has a past medical history of type 2 diabetes and hypertension. She has been vomiting frequently over the last 24 hours and has not been able to keep any fluids down. Drug History - Metformin 1 g PO BD - Ramipril 10 mg PO OD - NKDA On Examination The patient appears dehydrated with dry mucous membranes and decreased skin turgor. She is alert but in pain. Her blood pressure is 90/60 mmHg, pulse is 110 bpm, and she is afebrile. Investigations - Serum amylase of 600 U/L (normal range: 30-110 U/L). - Blood glucose 14 mmol/L, Urea 7.2 mmol/L (normal range: 2.5-6.7 mmol/L), creatinine 150 µmol/L (40-90 µmol/L). - Her arterial blood gas shows a pH of 7.31, HCO3- of 18 mmol/L, and a lactate of 3.2mmol/L QUESTION 2Prescribe ONE appropriate initial intravenous fluid for this patient PRESCRIPTION FORM MEDICINE NaCl 0.9% DOSE ROUTE 500ml IV FREQUENCY DURATION STAT 15 minutes PRESCRIBER DATE Dr A Aaronson XX/XX/XXXXAnswer: • This patient is acutely unwell with evidence of haemodynamic compromise. They therefore require fluid resuscitation. NICE guidelines suggest using a crystalloid that contains sodium in the range 130 to 154 mmol/l, with a bolus of 500 ml over less than 15 minutes. • Alternative answer: Hartmann’s solution 500ml IV stat over <15 minutes. • 5% glucose or 0.18%NaCl with 4% glucose would not achieve full marks Source: https://www.nice.org.uk/guidance/cg174/chapter/Recommendations#resuscitation-2 Mr. Thomas is a 58-year-old man who presents to his GP for a routine health checkup. He is a smoker with a 30-pack-year history and has recently been diagnosed with hypertension, for which he has not yet started treatment. He does not report any cardiovascular symptoms but is concerned about his heart health as his father had a myocardial infarction at the age of 60. Drug History: • No regular medications • NKDA On Examination: • BMI 29 kg/m² • Blood pressure 145/92mmHg on two separate occasions. • His heart rate is regular at 76 beats per minute, and his cardiovascular examination is otherwise unremarkable. Investigations: • Total cholesterol 6.2 mmol/L, HDL cholesterol 1.0 mmol/L, LDL cholesterol 4.0 mmol/L. • Kidney function and liver enzymes are within normal ranges. • His QRISK2 score is calculated to be 12%. QUESTION 3Write a prescription for ONE drug that is most appropriate for primary prevention of cardiovascular disease for this patient. PRESCRIPTION FORM MEDICINE Atorvastatin DOSE ROUTE 20mg PO FREQUENCY DURATION Once daily/ON Continuous PRESCRIBER DATE Dr A Aaronson XX/XX/XXXXAnswer: • NICE recommends atorvastatin 20mg once daily for primary prevention of cardiovascular disease in patients who are at increased risk, defined as a QRISK®2 score of >10%. • The QRISK®2 score is a tool used in the UK to estimate the risk of developing cardiovascular disease (CVD) over the next 10 years. • Less than full marks would be achieved if the dose of the statin is 10mg, 40mg or 80mg, or an alternative statin with an appropriate dose is prescribed. Source: https://bnf.nice.org.uk/treatment-summaries/cardiovascular-disease-risk-assessme nt-and-prevention/ A65-year-old woman presents to the outpatient clinic complaining of a painful, swollen left calf that has developed over the past two days. She recently underwent a total hip replacement 10 days ago. She has a history of hypertension, which is well-controlled on amlodipine, and she does not have any known drug allergies. Drug History: • Amlodipine 10mg once daily • Paracetamol 1g every 6 hours as needed for pain On Examination: • Temperature: 37.2°C • Pulse: 88 bpm, regular • Blood Pressure: 135/85 mmHg • Respiratory Rate: 18 breaths per minute • Oxygen saturation: 98% on room air • The left calf is erythematous, warm, and measures 3 cm more in circumference than the right calf. Investigations: • FBC, renal and liver function unremarkable, D-dimer: 1050ng/ml (<400) • Ultrasound doppler left leg: Thrombus in the left proximal popliteal vein QUESTION 4Write a prescription for ONE drug that is most appropriate to treat this patient. PRESCRIPTION FORM MEDICINE Apixaban DOSE ROUTE 10mg PO FREQUENCY DURATION BD 7 days PRESCRIBER DATE Dr A Aaronson XX/XX/XXXXAnswer: • For treatment of a PE or confirmed proximal DVT, NICE guidelines advise giving either apixaban or rivaroxaban first line. The prescriptions would be as follows: • Apixaban 10mg PO BD for 7 days then 5mg BD maintenance dose • Rivaroxaban 15mg PO BD for 21 days, followed by 20mg PO once daily • Total duration depends on whether the DVT was provoked (3 months) or unprovoked (6 months +) and individual patient risk factors • Candidates who prescribe a LMWH or other DOAC would not receive full marks here as these would be indicated only if apixaban or rivaroxaban were unsuitable Source: https://bnf.nice.org.uk/treatment-summaries/venous-thromboembolism/#venous-thromboembolis m-treatmentPRESCRIPTION REVIEW A35-year-old woman with a history of a ventricular septal defect presents with fever, palpitations and lethargy for two days. Blood cultures are taken, and an inpatient echocardiogram identifies vegetation on the tricuspid valve. She is diagnosed with infective endocarditis and started on empirical IV antibiotics, later adjusted based on the blood cultures. PMH: V entricular septal defect, depression. Allergies: Penicillin. DH: Listed below. QUESTION 5A: Select ONE prescription that is most likely to interact with the combined oral contraceptive pill (COCP) and reduce its effectiveness. (please tick the corresponding box(es) in column A) B: Select TWO prescription that would need to be stopped if the patient needs surgery (please tick the corresponding box(es) in column B) MEDICATION DOSE ROUTE FREQUENCY A B Sertraline 50mg PO OD Ethinylestradiol / Levonorgestrel 30 mcgPO50mcg OD Rifampicin 600mg IV BD Teicoplanin 800mg IV OD Enoxaparin 40mg SC ODAnswer: A: Rifampicin (It induces hepatic enzymes, increasing metabolism of COCP and reducing efficacy). B: Ethinylestradiol / Levonorgestrel and Enoxaparin (Increases the risk of venous thromboembolism/bleeding perioperatively).45-year-old lady presented to theA&E department with severe diarrhoea, muscle rigidity, shivering and a single episode of a 2 minute long self-terminating seizure. She lives with her partner with 2 children. Her partner informs you that she recently started taking a plant-based substance for her menopausal symptoms. She smokes 15 cigarettes a day, does not take alcohol or drugs, no recent travel, works as a teacher in a primary school PMH: Bipolar disorder, hypertension, mild depression, migraines, right knee osteoarthritis DH: Lithium,Amlodipine, Ramipril, Topiramate, Ibuprofen, Paracetamol. NKDA O/E • Pulse 120 beats per minute and BP 110/80 mmHg. Ix: • Temperature 37.9°C, oxygen saturations 97%. • Hb 140 g/L (120-150) • WCC 7.0 x 10^9/L (4.0 – 11.0) • Clinical examination suggests signs of dehydration. • CRP 39mg/L (<6) • Respiratory assessment reveals clear lung fields. • Creatine Kinase (CK) 650U/L (38-174) • Abdominal is soft and non-tender. • Urea 10mmol/L (2.5-7.8) • There is a noted presence of mild muscle rigidity, but • Serum Creatinine 180µmol/L (45-90) no other neurological deficits are identified. • K+ 4.8mmol/L (3.5-5.1), Na+ 130 mmol/L (135-145) • The patient has a Body Mass Index (BMI) of 39 • Lithium concentration 0.9 mmol/L (0.6 – 1.2) The medical SpR on the clinical take diagnoses serotonin syndrome and initiates medical management. QUESTION 6A: select TWO prescriptions that most likely contributed to her clinical presentation (please tick the corresponding box(es) in columnA) B: select the TWO prescriptions that have most likely contributed to her acute kidney injury (please tick the corresponding box(es) in column B) MEDICATION DOSE ROUTE FREQUENCY A B Lithium carbonate 300mg PO OD Ferrous fumarate 210mg PO OD Topiramate 50mg PO BD St Johns Wort (OTC preparation) 300mg PO OM Ramipril 10mg PO OM Paracetamol 1g PO QDS Diclofenac gel 1 application TOP PRN up to TDSAnswer: A: Lithium and St Johns Wort St John's Wort (SJW) is a CYP450 inducer, which typically reduces drug levels rather than increasing them. However, its interaction with lithium and risk of serotonin syndrome is not due to CYP450 induction but rather its effects on serotonin neurotransmission. B: Lithium and Ramipril Jonathan is a 72-year-old male who has come to the emergency department with complaints of light-headedness and a single episode of passing black tarry stool. PMH: Hypertension, benign prostatic hyperplasia, type 2 diabetes mellitus, recent myocardial infarction for which he had a stent placement six months ago. Observations: Pulse 45 bpm, BP 130/80 mmHg, RR 18 breaths per minute, Temp 36.6°C, sats 98% on room air Bloods: - Hb 112 g/L (dropped from 135 g/L over the last 6 months, Platelets 250 x 10^9/L, INR 1.0, Creatinine 98 µmol/L, eGFR 62 mL/min/1.73m^2 DH: see next QUESTION 7A: Select the TWO medications that have most likely contributed to this patient’s melaena (please tick the corresponding box(es) in columnA). B: Select the TWO medications that have most likely contributed to this patient’s bradycardia (please tick the corresponding box(es) in column B). MEDICATION DOSE ROUTE FREQUENCY A B Diclofenac 75mg PO BD Clopidogrel 75mg PO OD Gliclazide 80mg PO OD Tamsulosin 400 micrograms PO OD Indapamide 2.5mg PO OD Metoprolol 100mg PO BD Irbesartan 300mg PO OD Verapamil 240mg PO ODAnswer: A: Diclofenac and Clopidogrel • Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding. • Clopidogrel is an antiplatelet agent that inhibits blood clot formation, which increases the risk of bleeding. B: Metoprolol and Verapamil • Metoprolol is a beta-blocker that can cause bradycardia as it reduces myocardial contractility and suppresses the pacemaker activity. • Verapamil is a calcium channel blocker that can also lead to bradycardia by decreasing the automaticity of pacemaker cells and slowing down the conduction through theAV node. • Rate-limiting calcium channel blockers and beta-blockers should not be co-prescribed due to the risk of heart block Margaret is a 74-year-old woman who attends the clinic complaining of fatigue and occasional confusion, which has worsened over the last two months. She has a complex medical history and has been treated for multiple conditions over the years. She expresses concern about the number of pills she has to take daily and admits that she sometimes takes them at the wrong times because she finds the schedule confusing. PMH: Chronic obstructive pulmonary disease (COPD), atrial fibrillation, congestive heart failure, Chronic kidney disease stage 3a, depression Bloods: - Na+ 125 mmol/L, K+ 4.8 mmol/L, Creatinine 176 µmol/L, eGFR 35 mL/min/1.73m^2, Hb 108 g/L, WBC 5.6 x 10^9/L DH: see next QUESTION 8A: Select the ONE medication that when prescribed with digoxin, increases the risk of toxicity (please tick the corresponding box(es) in columnA). B: Select the THREE medications that, when taken together, are most likely to contribute to the patient’s hyponatraemia (please tick the corresponding box(es) in column B). MEDICATION DOSE ROUTE FREQUENCY A B Digoxin 125 micrograms PO OD Furosemide 40mg PO BD Warfarin Adjusted dose PO OD Sertraline 100mg PO OD Carvedilol 12.5mg PO BD Spironolactone 25mg PO OD Amitriptyline 10mg PO NOCTE Tiotropium 18 micrograms INH ODAnswer: A: furosemide B: furosemide, amitriptyline, sertraline • Furosemide increases the risk of hyponatremia by increasing excretion of sodium and water by inhibiting the Na+/K+/2Cl- transporter in the thick ascending limb of the loop of Henle in the kidneys. • Amitriptyline and sertraline increase the risk of hyponatraemia, particularly in the elderly, by causing SIADH. They may also lead to confusion, delirium and worsening of any existing cognitive impairment.PLANNING MANAGEMENT A45-year-old male patient presents to the emergency department unwell and unkempt. He is agitated, sweating, and reports visual hallucinations. His blood tests show a plasma magnesium of 0.6 mmol/L (normal range: 0.7-1.0 mmol/L) and a mean cell volume (MCV) of 108 fL (normal range: 80-96 fL). The patient reports drinking on average one 750ml bottle of vodka daily with his last drink approximately 48 hours ago. He takes no regular medications. Observations: blood pressure 160/90 mmHg, pulse 110 bpm, temperature 37.8°C, and respiratory rate 22 breaths/min Please select the most appropriate management option at this stage (mark with a tick). Management Option Prescribe IV sodium chloride 0.9% 1L over 8 hours Prescribe IV pabrinex (high potency B complex and vitamin C solution), two pairs over 30 minutes Prescribe NaCl 0.18%-glucose 4% with 40mmol KCl 1L over 8 hours Administer oral thiamine 100 mg once daily. Administer magnesium sulphate 2g (8mmol) in 100ml NaCl over 30 minutes QUESTION 9Answer: Prescribe IV pabrinex (high potency B complex and vitamin C solution), two pairs over 30 minutes - Patients with chronic alcoholism presenting in acute alcohol withdrawal are at high risk of Wernicke's encephalopathy due to thiamine (vitamin B1) deficiency. - The intravenous administration of pabrinex, which contains high doses of vitamin B1 as well as other B vitamins, is essential in the immediate treatment to prevent the development of Wernicke's encephalopathy. - Oral chlordiazepoxide reducing regime + PRN would also be required for the acute withdrawal symptoms such as agitation, tremors, and to prevent progression to more severe withdrawal symptoms such as seizures or delirium tremens. - Following chlordiazepoxide, thiamine 100 mg three times a day should be prescribed Source: https://bnf.nice.org.uk/drugs/vitamin-b-substances-with-ascorbic-acid/#indications-and-dose A25-year-old woman presents to her GP for a routine check-up. She has just discovered that she is six weeks pregnant and is concerned because her sister’s child was born with spina bifida. She enquires about what she can do to reduce the risk of neural tube defects in her baby. Considering her family history and current gestational age, which of the following is the single BEST course of action to reduce the risk of spina bifida in her unborn child? Management Option Advise her to start taking 400mcg of folic acid daily immediately Recommend an increase in dietary intake of leafy greens and citrus fruits Prescribe a high-dose folic acid supplement of 5 mg daily until 12 weeks of gestation Arrange for an immediate referral to a genetic counsellor Schedule an ultrasound to evaluate the development of the neural tube at her earliest convenience QUESTION 10Answer: Prescribe a high-dose folic acid supplement of 5 mg daily until 12 weeks of gestation • Women with a family history of neural tube defects (such as spina bifida) are at higher risk of having a child with the same condition. It is recommended that they take a higher dose of folic acid — 5 mg daily — from before conception and up to the 12th week of pregnancy. • This higher dosage is significantly more than the standard dose of 400mcg for women without a history indicating higher risk. Source: https://cks.nice.org.uk/topics/pre-conception-advice-management/management/advice-for-all-wo men/ A22-year-old female with a history of type 1 diabetes presents to theA&E with confusion, abdominal pain, and rapid breathing. Her blood glucose is reported as 28 mmol/L, and her arterial blood gas shows a pH of 7.1 and bicarb of 8 mmol/l. Ketones come back as 9 mmol/L. Please select the most appropriate management option at this stage (mark with a tick). Management Option Administer a bolus of 0.9% sodium chloride IV at 15 mL/kg body weight over the first hour Give a rapid-acting insulin analogue subcutaneously according to her usual dosing regimen Start an IV infusion of 10% dextrose at a rate of 100 mL/hr Initiate an IV insulin infusion at 1 unit/kg/hr Initiate an IV insulin infusion at 0.1 units/kg/hr without a bolus of insulin QUESTION 11Answer: Initiate an IV insulin infusion at 0.1 units/kg/hr without a bolus of insulin. • The initial management of DKAinvolves the correction of dehydration, hyperglycaemia, and electrolyte imbalances, and the cessation of ketogenesis. • NICE guidelines recommend starting with fluid replacement (usually 0.9% sodium chloride) and correcting electrolyte imbalances, particularly potassium. • However, the most immediate and specific action to address the underlying pathophysiology of DKAis the administration of insulin. The correct choice is to initiate an intravenous insulin infusion at a dose of 0.1 units/kg/hr without an initial bolus to avoid the risk of hypoglycaemia and cerebral oedema. This facilitates the gradual reduction in blood glucose and resolution of ketoacidosis. Source: https://abcd.care/resource/current/jbds-02-management-diabetic-ketoacidosis-adults A58-year-old male patient with a history of primary hypertension is being reviewed in the hypertension clinic. He currently takesAmlodipine 10 mg once daily and Ramipril 10 mg once daily. His most recent ambulatory blood pressure monitoring (ABPM) reading shows: • Average 24-hour blood pressure 154/94mmHg He has no history of diabetes or renal impairment. His serum potassium is 4.2 mmol/L and eGFR >60 mL/min/1.73m². Please select the most appropriate management option at this stage (mark with a tick). Options Initiate Bendroflumethiazide 2.5 mg once daily Initiate Doxazosin 4 mg once daily Initiate Bisoprolol 2.5 mg once daily Initiate Spironolactone 25 mg once daily Initiate Indapamide 2.5mg once daily QUESTION 12Answer: Initiate Indapamide 2.5mg once daily • This is step 3 treatment of primary hypertension where a patient is already on maximum doses of step 1 and step 2 treatment • A+ C + D (ACE inhibitor orAngiotensin II receptor blocker + Calcium channel blocker + Thiazide-like Diuretic) • Athiazide-like diuretic (indapamide) would therefore be the next most appropriate drug • Spironolactone would be appropriate if the patient had already been on indapamide (step 4 treatment) • Alpha and beta-blockers are typically used in step 4 management where a potassium-sparing diuretic (spironolactone) is contraindicated e.g. serum potassium > 4.5 mmol/l • The NICE guidelines specifically thiazide-like diuretics such as indapamide should be used in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide, hence option (A) is not the single best answer. Source: https://www.nice.org.uk/guidance/ng136/chapter/RecommendationsPROVIDING INFORMATION You are a junior doctor and have just initiated dapagliflozin for Mr. Jones, a 58-year-old patient with type 2 diabetes. Mr. Jones asks you to explain how this new medication will help him manage his diabetes. Select the one most appropriate piece of information to give Mr Jones regarding how his new medication works mark with a tick in the corresponding box).   Dapagliflozin will increase the amount of insulin the pancreas produces, which is essential for controlling blood sugar levels   Dapagliflozin helps muscles absorb more sugar from the blood, thus reducing blood sugar levels   Dapagliflozin blocks sugars from being reabsorbed by the kidneys, so more sugar is passed out of the body in the urine   Dapagliflozin decreases the amount of sugar the liver makes, which helps to lower blood sugar levels   Dapagliflozin slows down our digestion so that sugar enters the bloodstream more slowly after eating QUESTION 13Answer: Dapagliflozin blocks sugars from being reabsorbed by the kidneys, so more sugar is passed out of the body in the urine • Dapagliflozin is an SGLT2 inhibitor. These medications inhibit the sodium-glucose co-transporter 2 protein in the renal proximal convoluted tubule. When this protein is blocked, less glucose is reabsorbed from the urine back into the blood. • Side effects include increased risk of UTI and normoglycemic ketoacidosis https://bnf.nice.org.uk/drugs/dapagliflozin/ Javed, a 26-year-old gentleman, was diagnosed with Tuberculosis a month ago. He was started on Rifampicin along with three other antibiotics. He presented to his GP due to noticing reddish-coloured urine. He was particularly worried that he might have cancer in the bladder. Blood tests: Unremarkable PMH: Nil Urine Dip: · pH: 6 (Normal range 5-9) · Specific Gravity: 1.023 (Normal range 1.003-1.030) · Nitrites : Negative · Protein: Negative · Glucose: Negative · Ketone: Negative · Bilirubin: Negative · Blood: Negative QUESTION 14Select the one most appropriate piece of information to give Javed regarding his presenting complaint by marking with a star in the corresponding box.   Advise him to stop taking Rifampicin   Advised him to present to A&E urgently   Reassure him that it is one of the side effects of Rifampicin and he should continue taking it as prescribed   Refer him to urology for a two week wait flexible cystoscopy   Refer him to nephrology for further for a full renal workupAnswer: Reassure him that it is one of the side effects of Rifampicin and he should continue taking it as prescribed Explanation: Red discoloration of the body fluids is one of the side effects of Rifampicin. Rifampicin itself is a red-coloured drug which can discolour bodily fluids. Source: https://bnf.nice.org.uk/drugs/rifampicin/#side-effects You initiated treatment with denosumab for a 65-year-old woman with osteoporosis. She enquires about the administration of this new medication. Select the one most appropriate explanation of how denosumab should be administered (mark with a star in the corresponding box). “Denosumab is taken orally, one tablet per week with a glass of water, first thing in the morning before   breakfast” “Denosumab is an injectable medication. You will receive an injection under the skin (subcutaneously) every 3 months by a healthcare professional”   “Denosumab is an injectable medication. You will receive an injection under the skin (subcutaneously) every 6 months by a healthcare professional”   “Denosumab requires intravenous infusion, which will be given to you at the clinic every three months."   “Denosumab requires intravenous infusion, which will be given to you at the clinic every six months."   QUESTION 15Answer: “Denosumab is an injectable medication. You will receive an injection under the skin (subcutaneously) every 6 months by a healthcare professional” • Denosumab is a human monoclonal antibody that inhibits osteoclast formation, function, and survival, thereby decreasing bone resorption. • It is given via S/C injection every 6 months Source: https://bnf.nice.org.uk/drugs/denosumab/CALCULATION SKILLS A70-year-old man with chronic kidney disease requires an IV infusion of vancomycin for a severe bacterial infection. His creatinine clearance is calculated to be 30 mL/min, and the recommended dose of vancomycin is 15 mg/kg body weight given every 12 hours. He weighs 68 kg. Vancomycin is available as a 500 mg vial which should be diluted in 100 mL of 0.9% sodium chloride solution before administration. What volume of the diluted vancomycin solution, to the nearest 10ml, should be administered every 12 hours? Answer: 200ml • First, determine the total dose of vancomycin needed per administration based on the patient's weight: 68 kg ×15 mg/kg = 1020 mg • Since each vial after dilution contains 500 mg and we need to administer 1020 mg, we calculate how many millilitres are required to deliver this dose: o 1020 mg/500 mg/vial =2.04 vials • Each vial is diluted in 100 mL, so the total volume for 2.04 vials is: o 2.04 vials × 100 mL/vial = 204 mL • To the nearest 10ml, 200mL of the diluted vancomycin solution should be given every 12 hours. QUESTION 16 A54-year-old man with a history of chronic heart failure is prescribed furosemide to reduce fluid retention. The target furosemide dose is 2 mg/kg due to his current symptoms and recent weight gain. The patient weighs 90 kg. The furosemide in stock is available in 20 mg tablets. How many tablets should the patient take per dose? Answer: 9 tablets • 2mg/kg x 90kg = 180mg total dose • 180mg/20mg tablets = 9 tablets QUESTION 17 A68-year-old man with a history of chronic kidney disease is prescribed a single dose of gentamicin for a severe bacterial infection. The dose of gentamicin is calculated based on his ideal body weight (IBW) and creatinine clearance. The prescribed dose is 3 mg/kg IBW, administered as a single IV dose. The patient's IBW is calculated at 76 kg and his creatinine clearance (CrCl) is 45 ml/min. Gentamicin is available in a concentration of 10 mg/ml. How many millilitres of gentamicin, to the nearest ml, should be administered for the single dose? Answer: 23ml • First, calculate the total dose of gentamicin needed based on the patient's IBW: Total dose = 3 mg/kg × 76 kg = 228 mg. • Next, determine the volume of gentamicin solution required to provide the total dose: Volume required = Total dose / Concentration of gentamicin Volume required = 228 mg / 10 mg/ml = 22.8 ml. • Rounded to the nearest ml, the patient should receive 23ml of gentamicin QUESTION 18 A66-year-old man with a history of alcohol misuse is admitted to the gastroenterology ward with signs of Wernicke's encephalopathy. He requires urgent treatment with intravenous thiamine. The prescribed dose is 500 mg of thiamine each day, to be administered over two doses. The available thiamine stock solution contains 100 mg of thiamine in 50 ml of saline. Calculate the volume of thiamine solution needed per administration in ml. Answer: 125ml thiamine solution • Each dose of thiamine should be 250mg • 250/100 = 2.5 • 2.5 x 50ml = 125ml thiamine solution QUESTION 19ADVERSE DRUG REACTIONS 67-year-old with a mechanical heart valve on warfarin had a small nosebleed last night that self-terminated after 10 seconds. They present to their GP for advice. On examination there is no evidence of active bleeding. There has been no recent dietary change and no change in bowel habit. He has currently completed 5 days of a 7-day course of erythromycin prescribed by his dermatologist for impetigo. The GP requests an urgent INR which comes back as 6.6. His target INR is 2.5-3.5. QUESTION 20Select from the following options the most appropriate advice the GP should give this patient. Options   Stop erythromycin, withhold 1 or 2 doses of warfarin, then re-start at the normal dose   Stop erythromycin, stop warfarin, give intravenous vitamin K 1-3mg, re-start when INR < 5.0   Withhold warfarin for 1 or 2 doses, then re-start at the normal dose   Stop warfarin, and refer urgently for intravenous treatment with phytomenadione (vitamin K ) and 1 dried prothrombin complex concentrate   Stop warfarin and prescribe a direct oral anticoagulant instead Answer: Stop erythromycin, withhold 1 or 2 doses of warfarin, then re-start at the normal dose • Erythromycin is a cytochrome P450 inhibitor which increases the anticoagulant effect of warfarin • The first step in this scenario is to stop erythromycin.After 5 days the impetigo may be treated, otherwise an alternative antibiotic should be prescribed • The guidelines on the management of high INR in patients on warfarin as are follows: Clinical Presentation Management Major bleed Stop warfarin, give 5mg IV vit K and give PCC INR >8.0 with minor bleeding Stop warfarin, give 5mg IV vit K and re-start warfarin when INR <5.0 INR >8.0 with no bleeding Stop warfarin, given oral vit K and re-start warfarin when INR <5.0 INR 5.0 – 8.0 with minor bleeding Stop warfarin, give 5mg IV vit K and re-start warfarin when INR <5.0 INR 5.0 – 8.0 with no bleeding Withhold 1 or 2 doses of warfarin. Reduce subsequent maintenance dose if no other cause Source: https://bnf.nice.org.uk/treatment-summaries/oral-anticoagulants/ • As the patient is not actively bleeding in this scenario, the best option is to stop erythromycin, hold warfarin for 1 or 2 doses then re-start. In reality you would continue monitoring the INR and ensure appropriate follow up to ensure INR remains in range following discontinuation of erythromycin. Mrs. Lewis, a 62-year-old female presented to the emergency department with headache, severe nausea and vomiting. Her CT head and lumbar puncture are unremarkable. The following drugs are commenced while awaiting the neurology and ENT review: · SC enoxaparin 40mg OD · PO Paracetamol 1G QDS · PO betahistine 16mg TDS · IV metoclopramide 10mg TDS · IV ondansetron 4mg BD PMH: depression and hypothyroidism Regular medications: Citalopram 20mg OD and Levothyroxine 50 microgram OD On day 2 of the admission, she develops palpitations and her ECG shows prolong QTc (480ms). QUESTION 21Select from the following medications the most likely responsible for this ECG abnormality when prescribed with the patient’s regular medications. Options Enoxaparin   Paracetamol   Betahistine   Metoclopramide   Ondansetron  Answer: Ondansetron Explanation: • Both Citalopram and Ondansetron can prolong the QT interval and both can also increase risk of serotonin syndrome. • Increased risk is associated with older age, female sex and underlying cardiac disease. • Hypokalaemia can also exacerbate prolong QTc and lead to cardiac arrest. MrAnderson, a 32 year old male, has been started on clozapine after trying several other types of antipsychotics for his schizophrenia. It requires weekly blood tests for the first 18 weeks of therapy; Select the one most important adverse effect that requires monitoring for from the list below. Options Prolactinaemia Constipation  Parkinsonism Neutropenia  Hyperglycaemia  QUESTION 22Answer: Neutropenia Atypical antipsychotics Leucocyte and differential blood counts must be normal before starting treatment https://bnf.nice.org.uk/drugs/clozapine/#monitoring-requirements For prolactin levels monitoring is only required before, at 6 months and at 1 year of treatment. Differential white blood count: weekly for 18 weeks, then every 2 weeks up to one year An 88-year-old lady admits toA&E following a fall. Xray hips and pelvis reveals a left sided neck of femur fracture. On further history she reports feeling lightheaded over the preceding few days with intermittent dizzy spells. She thinks that she had one of these dizzy spells prior to the fall but did not lose consciousness. PMH: Depression, hypertension, impaired glucose tolerance, osteoarthritis, constipation The orthogeriatric consultant advised you to review her medications as they suspect they may be implicated in the fall. QUESTION 23Select from the following list the most likely medication that has contributed to this patient’s fall. Options Losartan   Bendroflumethiazide   Doxazosin   Quetiapine   All the above  Answer: all the above Common drugs that contribute to falls: Antidepressants - Can lower blood pressure, cause confusion, dizziness and drowsiness Benzodiazepines - Will cause drowsiness. Diuretics - Can dehydrate and lower blood pressure. Antihypertensives - Can lower blood pressure and pulse. Antipsychotics - Can cause confusion and drowsiness. Laxatives - Can cause dehydration Painkillers - Can cause confusion and sedation Antihistamines - Can cause drowsiness. Non-drowsy options are available.DRUG MONITORING A68-year-old female with a history of heart failure was admitted to the hospital with acute pulmonary oedema. She has been commenced on bumetanide. Which of the following is the MOST important parameter to monitor regularly in this patient to minimize the risk of adverse effects associated with bumetanide? Options   ECG   Echocardiogram   Serum potassium levels   Daily weights   Serum creatinine levels QUESTION 24Answer: serum potassium levels • Electrolytes are the most important parameters to monitor to prevent adverse effects of loop diuretics • ECG, echocardiogram, creatinine and daily weights are also important in the management of acute pulmonary oedema/decompensated heart failure, but electrolytes are the most important to monitor for adverse effects of the drug A72-year-old patient is on day 5 of treatment following an admission with a pulmonary embolism. He has been taking enoxaparin 120mg once daily and is being prepared for a possible discharge the following day as he has progressed well with his treatment. He will continue on enoxaparin to complete a 2 weeks course then change to apixaban. Blood tests on admission were unremarkable except for a D-dimer of >5000 ng/ml. He has not had any blood tests repeated since. Which of the following blood tests is the most appropriate to perform prior to his discharge? Options   Full clotting profile   Full blood count   Anti-Xa assay   INR   Activated Partial Thromboplastin Time (aPTT) QUESTION 25Answer: full blood count • Heparin-induced thrombocytopaenia (HIT) is a potentially life threatening adverse effect of administering heparins • The BNF advises platelet counts should be measured just before treatment with unfractionated or low molecular weight heparin, and regular monitoring of platelet counts may be required if given for longer than 4 days. • The anticoagulant activity of LMWHs can be monitored using theAnti-Xa assay, however this does not give us information about potential adverse effects of therapy. Source: https://bnf.nice.org.uk/drugs/enoxaparin-sodium/#monitoring-requirements A70-year-old patient with a history of chronic kidney disease (stage 3) has been diagnosed with a severe Methicillin-resistant Staphylococcus aureus (MRSA) infection. The patient has been prescribed vancomycin, and you are responsible for monitoring the patient's response to the medication. Which of the following is the most appropriate monitoring strategy for this patient to ensure both efficacy and safety of vancomycin therapy? Options   Measure trough levels only, aiming for a range of 10-15 mg/L   Measure peak levels only, two hours post-dose   Measure both trough and peak levels, aiming for a trough level of 15-20 mg/L and a peak level of 20-40 mg/L   Measure trough levels only, aiming for a range of 15-20 mg/L   No monitoring is required as long as the patient’s renal function is stable. QUESTION 26Answer: Measure trough levels only, aiming for a range of 15-20 mg/L • It is essential to monitor vancomycin levels in patients with chronic kidney disease due to their reduced ability to excrete the drug, which can lead to accumulation and toxicity. • The recommended vancomycin trough concentration for serious infections is 15-20 mg/L. • Monitoring trough levels (just before the next dose) is crucial as it helps to ensure therapeutic efficacy and minimize toxicity. • Monitoring peak levels (2 hours post-dose) is generally not necessary for vancomycin, as trough levels are more predictive of efficacy and toxicity. Source: https://bnf.nice.org.uk/drugs/vancomycin/ You are currently treating a 55-year-old female patient who has recently been diagnosed with Type 2 diabetes. She has a BMI of 32 and her recent HbA1c level is 57mmol/mol. She has no history of kidney disease, and her baseline renal function and liver function tests are within normal limits. You have initiated treatment with metformin. Seven weeks after starting metformin, the patient returns for a routine follow-up appointment. Which is the most appropriate monitoring to perform for this patient? Options   No monitoring is currently required   Repeat renal function at this appointment   Perform FBC, renal function and liver function at this appointment   Perform renal function monitoring every 6 months   Repeat HbA1C in 1 week QUESTION 27Answer: no monitoring is currently required • The BNF advises performing renal function before treatment and at least annually thereafter for patients on metformin • For patients with additional risk factors, renal function can be performed twice a year (this is not the case here) • FBC and liver function do not routinely need to be monitored for patients on metformin • HbA1C is typically re-checked 3 months after starting metforminDATA INTERPRETATION You are the FY1 on call on medical nights. You are tasked to review a 68-year-old male with chronic kidney disease who presented to the emergency department with weakness and palpitations and is currently being managed on the acute medical unit. His blood tests reveal a serum potassium level of 6.8 mmol/L, and an ECG shows tall peaked T waves. What is the most appropriate initial management option? Options Phone the ITU registrar on call for consideration of haemodialysis   Give sodium zirconium 10mg orally   Give IV calcium gluconate 30ml 10%   Given 8U of rapid acting insulin in 100ml 20% dextrose solution   Give 5mg salbutamol via inhaled nebuliser   QUESTION 28Answer: Give IV calcium gluconate 30ml 10% • This patient has severe hyperkalaemia ((≥ 6.5 mmol/L) with ECG changes. This warrants emergency treatment. • The first step is to stabilise the cardiac membrane with IV calcium gluconate rapidly followed by insulin-dextrose which will cause a short term shift in potassium from the extracellular to intraceullular fluid. • Other treatments can then be considered such as nebulised salbutamol and calcium resonium. • Sodium zirconium is an ion exchange resin that is used in the management of mild or moderate hyperkalaemia with no ECG changes. Reductions in serum potassium concentrations take 24-48 hours therefore it is not appropriate in an emergency setting. • Haemaodialysis may well be indicated in refractory hyperkalaemia however it is not the first line option Source: https://bnf.nice.org.uk/treatment-summaries/fluids-and-electrolytes/ A56-year-old female patient with a history of bipolar disorder presents to the community psychiatry clinic for a routine follow up. She has been stable on lithium carbonate for the past 2 years. She has no complaints and is adherent to her medication. Her current lithium dose is 800 mg daily. Her blood test results today show a serum lithium level of 1.5 mmol/L. Her renal function is normal and there are no signs of lithium toxicity. What is the MOST appropriate initial action to take regarding her lithium therapy? Options Increase the lithium dose to achieve a higher therapeutic level, since she has no signs of toxicity.   Maintain the current lithium dose and recheck the level in 3 months, as the patient is asymptomatic   Advise the patient to stop taking lithium immediately and reassess in a week   Reduce the lithium dose and arrange to recheck the lithium level in 1 week   Add a second mood stabilizer to reduce the lithium dose needed for therapeutic effect   QUESTION 29Answer: Reduce the lithium dose and arrange to recheck the lithium level in 1 week • The therapeutic range for lithium is between 0.4 to 1.0 mmol/L for maintenance therapy. • Alevel of 1.5 mmol/L is above the therapeutic range and could increase the risk of lithium toxicity, even if the patient is currently asymptomatic. • It is appropriate to reduce the lithium dose and closely monitor the patient's serum levels. • Rechecking within a short period (e.g., 1 week) is essential to ensure that the lithium level returns to within the therapeutic range and to avoid toxicity. • Immediate discontinuation is not advised unless there are signs of toxicity or significantly higher levels, and adding another mood stabilizer is not the standard initial step in managing elevated lithium levels without clinical indications. • NICE guidelines state that “referral to secondary care may be required depending on the severity of symptoms and the certainty of toxicity. Use clinical judgement to determine the urgency of referral.”As the patient is currently asymptomatic and not displaying any signs of lithium toxicity, reducing the dose with repeat levels and close monitoring would be appropriate at this stage. Source: https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/lithium/ Jenny, a 32-year-old lady, attends the GP for hypothyroidism follow up. She is on levothyroxine 75 microgram OD. She reported that she missed her OC pill for 3 days 6 weeks ago and she has had a positive home pregnancy test. Her thyroid function today shows the following: TSH: 2 mu/l (0.5 - 5.5 mu/l) Free thyroxine (T4): 12 pmol/l (9-18 pmol/l) Total thyroxine (T4): 115 nmol/l (70 - 140 nmol/l) Select the one most appropriate course of action from the following options Options   Change levothyroxine to an alternative while the patient is pregnant, then resume at a lower dose   Continue the current dose of levothyroxine and monitor TFTs throughout the pregnancy   Reduce the current dose of levothyroxine by 25mcg and monitor TFTs throughout the pregnancy   Increase the current dose of levothyroxine by 25mcg and monitor TFTs throughout the pregnancy   Double the dose of levothyroxine and monitor TFTs throughout the pregnancy QUESTION 30Answer: Answer: Increase the current dose of levothyroxine by 25mcg and monitor TFTs throughout the pregnancy There is a higher requirement for thyroxine during pregnancy Excessive or insufficient maternal thyroid hormones can be detrimental to foetus The need of levothyroxine increases during first 20 week of pregnancy to prevent neonatal hypothyroidism In reality involvement of an endocrinologist is important. This option is not given here Increasing the dose of levothyroxine by 25-50mcg with TFT monitoring is the best answer from the options https://cks.nice.org.uk/topics/hypothyroidism/management/preconception-or-pregnant/#management https://bnf.nice.org.uk/drugs/levothyroxine-sodium/#pregnancyQUESTIONS?Pass the PSA, Second Edition https://prescribingsafetyassessment.ac.uk/resources/PSA-Bl ueprint.pdf Joint Formulary Committee (2021) British National Formulary. Available at: https://www-medicinescomplete-com.apollo.worc.ac.uk/ #/browse/bnf REFERENCES