IM ketoralac and valium. What do
you have to ask about?
GORD, bleeding tendency, driving machinery.
Which pathological states result in hyperkalemia?
diet, CRF/ARF(SLE, DM),NSAID use potassium supplements, diuretics eg: spironolactone. ACE-i.
Definition - Pain?
an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Types of pain:
-Acute pain: usually has a trigger, lasts for a short duration approx up to 3/52 (variable). Inflammation is the causative process.
-Chronic pain: present after injury has healed, usually assoc with an emotional aspect (depression, anxiety, hopelessness) and physical compensatory effects (hypertonicity, LOE, LOA).
-Neuropathic pain: complex, usually seen with diseases that damage neurological systems eg MS, shingles, phantom limb etc. Can be intense shooting, burning, P&N.
What controls pain?
higher cortical areas; at a minimum the thalamic areas.
Pain mechanisms: Inflammation
What is the cellular component?
This occurs at the microscopic level where damage occurs, starting a cascade of events
Pain Mechanisms: Inflammation
What is the neurological level?
The pathways that lead finally to processing of pain signals at the cortical level. Invloves the spinothalamic tracts, somato-sensory area (S1) and its projections to the amygdala, hippocampal, frontal areas of the brain which result in the experimental component of pain and suffering. Chemical changes at each juncture
What are the key features of inflammation?
Redness, Swelling, Heat, Pain and loss of function.
What does cell membrane damage lead to?
Phospholipids realease Arachidonic acid (Aa) via Phospholipase C and A2
Increase in intracellular Aa
Free Aa the undergoes metabolism by 2 pathways - COX & LOX
Present in normal cell homeostasis (kidney, gastric mucosa, airways and platlets)
What is COX2?
Is supposed to be more pro-inflammatory and selective COX2 inhibitors like Celebrex and Vioxx (withdrawn) were supposed to have less COX1 effects. Vioxx was PRO-thrombotic and gastric SE were not much different in either.
What does LOX do?
End up with formation of LTB4 & LTE4. High concentrations in mast cells, marcophages, neuts etc. Seem to be involved in asthma.
Prostaglandin is needed for gastric mucosa secretion and NSAIDs stop this. What does this result in?
Prostaglandin increases GFR in the kidneys. In the elderly what needs to be monitored?
The use of NSAIDs as they decrease GFR and in the elderly this is already decreased.
Nausea, mouth ulcers, pancytopenia, fibrosis and cirrhosis of the liver
What does leflunomide do?
Blocks synthesis of pyridoxines and inhibits activated lymphocytes
What are the side effects of leflunomide and when should it not be used?
Liver dysfunction, diarrhoea, alopecia, rash
In pregnant women - teratogenic
What do gold salts (sodium aurothiomalate) do and what are their side effects?
Inhibits T-cells and phagocytes
SE: Itch, eczema, gold deposits, aplastic anaemia
What is hydroxychloroquine, what was it previously used for and what are it's side effects
Supresses inflammatory response
Used previously to treat malaria
Nausea, rash, dizziness
What are cyclophosphamide and Cyclosporin and what is a common side effect?
Immune suppressants. Used in post-transplant patients or with sever rheumatologic disease
Renal toxicity is common
What do biologic DMARDS do, what are the SE and how much does it cost?
Tumour Necrosis Factor is released in inflammation. TNF inhibitors like etanercept and infliximab are monoclonal antibodies which bind and inactivate it
SE: Hypersensitivity and infections
Cost: $847 per infusion
What needs to be monitored during treatment?
Clinical monitoring: Pain, function, synovitis
Lab monitoring: CRP, ESR, antibody titre eg. rheumatic factor, ANA titre
How is gout treated?
NSAIDS esp - colchicine - inhibits mirotubule formation and decreases phagocytosis. Prednisolone can me used
Prevention is dependant on cause
How does PTH increase serum Ca?
Increasing bone turn over
Reabsorbing renal and GIT
Ca at the expense of Phos
Increases Vit D activation to 1,25 dihydroxy-vitamin D
List some examples of Microbes:
Prions, Viruses, Bacteria, Fungi, Parasites
What is Creutzfeldt-Jakob Disease?
A prion . Human variant of mad cow disease aka Bovine Spongiform encephalopathy which causes neuro-degenerative disease in the brain and spinal cord. No known cure
What is a virus? Give some examples
Consists of nucleic acid (RNA or DNA) surrounded by a protective protein coat (capsid). It attaches itself to the cell wall and inserts its nucleic acid which incorporates into the host DNA to form more virions.
Rhinovirus, to the exotic viruses like Herpes Simplex or HIV
List the 5 steps of virus replication:
1) Absorption and penetration of host cell
2) Synthesis of early non structural proteins. Eg. nucleic acid polymerases.
3) Synthesis of RNA or DNA.
4) Synthesis of late structural proteins.
5) Assembly and maturation with release of virions.
Retrovirus with long incubation period. RNA is converted to DNA by reverse transcriptase. High genetic variability due to high replication rate with new variants of protein structure- which allow evasion from host immune system.
Infects CD4 T-helper cells- loss of cell-mediated immunity & subsequent rise in opportunistic infections
In HAART, What are the three anti viral drugs used in conjunction to traet HIV?
Heparin: binds to Anti thrombin (IIa) and increases potency by x 1000.
Derivatives like enoxaparin (clexane) inhibit anti-Factor Xa activity.
SE: osteoporosis, thrombocytopaenia, haemorrhage,
Commonly used for Atrial Fibrillation and DVT prevention.
Impairs utilisation of Vit K and stops formation of F2,7,9,10 (TV channels)
Needs to be monitored with INR INR easily affected by other drugs eg amiodarone, panadol etc
Signs of overdose: Haematemesis/malena, haemoptysis, spont nose bleeds, gum bleeds, bruising
What are the contraindications for clot busters?
Elderly, pregnancy, retinal disease, recent surgery or stroke
Sensitivity of a drug is affected by the following factors
c)Age of the patient
e)All of the above.
Renal Excretion capability may be compromised in the following situations:
c)Long term NSAID use
d)Polycystic kidney disease
e)All of the above.
Significant factors affecting absorption with oral administration include
a)Autoimmune disease eg. Crohn’s disease
d)Lack of co-factors for absorption
e)All of the above
Which of the following is incorrect regarding routes of administration
a)IV is the quickest and most direct route
b)Oral administration is the slowest route
c)Rectal absorption is the slowest route
d)Topical applications by-pass 1st pass metabolism
e)Sublingual applications by pass 1st pass metabolism
Which of the following is incorrect in regards to pain medication:
a)Paracetamol should be given regularly for maximum effect
b)NSAIDS are a good choice in pregnancy related back pain
c)Laxatives should be prescribed in conjunction with long term opiate use
d)Short term use of opiates rarely leads to addiction
e)Morphine causes dysphoria in certain cases
Glucocorticoids have the following side effects & actions
b)Predisposes to vertebral compression fractures
c)Increase insulin activity
d)A & B are correct
e)Only B is correct
Colchicine (NSAID) is used to treat gout but may have the following side-effects except:
d)Increase in platelet activity
Short term Benzodiazepines may be indicated in the following cases
a)Patients with emphysema with cyanosis on minimal exertion with difficulty sleeping
b)Insomnia from the loss of a loved one
c)A patient with a headache after a concussion
d)Narcolepsy (sudden/unpredictable sleep onset)
e)Patients operating heavy machinery
Current treatment for Osteoporosis include the following except:
a)Bright light therapy
b)Adequete supplementary calcium and Vit D intake
d)Regular weight bearing exercise
Regarding Bisphosphonates (eg Fosamax) in the treatment of osteoporosis
a)They may be prescribed on suspicion of osteoporosis in a patient
b)Can cause oesophagitis
c)All patients need a dental review prior to commencement of therapy
d)Needs to be taken on an empty stomach immediately before sleep for maximum absorption
e)A & D are incorrect
Which of the following is incorrect in regards to Glyceryl Trinitrate sprays,
a)Repetitive use (after 3 attempts without relief) is an indication for urgent medical assessment
b)Is safest used sitting or lying down
c)Takes approximately 15 mins to work d)Causes veno-dilatation predominantly
e)May cause a headache
Statins (Atorvastatin / Lipitor) work by
a)Decreasing Low density lipo-proteins (LDL’s)
b)Stabilisation of the athersclerotic plaque
c) Inhibiting HMG Co-A reductase
d) All of the above are correct
Oral anti-hyperglycaemic agents should be started immediately on a patient who has impaired glucose tolerance
Good control in a px with impaired glucose tolerance requires:
a)Patient education & compliance
c)An insulin pump
d)Combinations of oral hyperglycaemic agents
e)Only a & b are correct
History taking of a NIDDM patient on oral hyperglycaemics (OHG) include the following:
a)Time of diagnosis and OHG initiation b)Use of beta blockers
c)Increasing Oedema, fatigue and nocturia
d)Recognition of hypoglycaemic effects e)All of the above are correct
Cardiac Risk factors for Ischaemic Heart Disease include the following except
a)Type 1 Diabetes Mellitus
d)Obstructive Sleep Apnea
Antibiotics affecting folate metabolism such as trimethoprim are safe and appropriate in the following except:
a)Patients with Cancer
c)High performance Athlete
d)Patients with Macrocytic Anaemia
e)B & D only
In regards to Aspirin, which of the following is false?
a)It binds reversibly with platelets
b)It has a strong effect on Thromboxane A2
c)It may cause a malena (blood in stool)
d)Works by inhibiting the COX pathway e)Low dose may be used in pregnancy with patients who have SLE and recurrent miscarriages
Anti-epileptic drugs like gabapentin may be useful in the treatment of
a)Tonic-clonic seizure activity
c)Phantom limb pain
e)A, b and c are correct
Appropriate therapy in a healthy young individual with an acute prolapsed disc causing SEVERE pain includes the following:
a) Paracetamol, Voltaren (NSAID)
B) gabapentin (anti-epileptic)
C) Paracetamol, Voltaren, oxynorm (opiate), diazepam (gaba-agonist)
D) TENS and heat therapy only
E) Oxynorm and gabapentin only
An elderly patient on warfarin presenting with headaches should be screened for:
A) Temporal arteritis
B) Subdural Haemorrhage
C) Raised intracranial pressure
D) all the above are correct
E) only a and c are correct
Osteoporosis is associated with which of the following:
A) Femoral neck fracture
B) Greenstick fracture
C) Colle’s fracture
D) sternal fracture
E) A and C are correct
Risk factors for osteoporosis does not include:
A) Nursing home residents
B) Using the oral contraceptive pill
C) Menopause at 42 years old
D) Bilateral Oophrectomy (ovary removal) during adolescence
E) Use of prednisolone for long term control of eczema
Beta blockers should be used with caution in which of the following situations:
A) Severe asthmatics
B) Peripheral Vascular disease
C) Diabetic patients on insulin
D) Patients with low blood pressure
E) All of the above
Anti- viral therapy includes the following
A) Neuro-aminidase inhibitors
C) Erythromycin (macrolide)
D) A & C are correct
E) A & B are correct
In regards to HIV therapy:
A) monitoring CD4 counts and viral loads are indicative of viral activity
B) HIV has a long latent period
C) Monotherapy with a single agent is the best option
D) A & B are correct
E) B is the only correct option
Which of the following in regards to asthma is incorrect
A) It is linked with hayfever, eczema and other allergies
B) Beta blockers are the mainstay of treatment
C) Steroids should be used if initial therapy is not adequete
D) Flares are more common in winter months
E) It is a bronchospasm involving small airways
Severe asthma attacks may require treatment with
C) Invasive ventilation
D) Ipratropium bromide (parasympathetic antagonist)
E) All of the above
Tricyclic Anti-depressants may cause the following side effects
A) cardiac arrythmias
B) dry mouth
C) Urinary retention
D) dry eyes
E) All of the above