3 □ is indicated in babies at birth to prevent vitamin K deficiency   1 □ cannot be used at the same dose as heparin   Q22 A patient who will be undergoing a colonoscopy is advised to:   1 Q a paediatric patient with a history of asthma who presents    Q24 Anti-infectives that are used in the triple-therapy regimens to eradicate  Helicobacter pylori include:   patient profile and answer the questions. For questions with  one or more correct answers, follow the key given with each  question. For the other questions, only one answer is correct  - give the corresponding answer.   PS is hospitalised with pulmonary oedema. Patient is started on metolazone  2.5 mg daily and bumetanide 2 mg bd iv   CA is a 77-year-old patient who is admitted to hospital with infected multiple sores  and who is complaining of polyuria and weakness. CA presented with reduced  skin turgor, dehydration, tremor and in a confused state. CA has a past medical  history of diabetes. Her general practitioner has started her the day before on  ciprofloxacin 250 mg bd and fusidic acid cream bd. Diabetes was managed  through dietary control and CA was not taking antidiabetic drugs. On admission,  CA is started on:   glibenclamide 2.5 mg daily  ciprofloxacin 500 mg bd  sodium chloride 0 . 9 % iv infusion  haloperidol 0.5 mg bd   On admission: random blood glucose level 12 mmol/l  blood pressure 125/78 mmHg   Q33 Parameters that need to be monitored to assess outcomes of therapy  include:    Q35 Pharmacist intervention with regards to therapy started on admission  includes:   A Q gliclazide is preferred in this patient  B □ the dose could be increased to 1 0 mg daily   D □ the drug reduces insulin secretion  E □ it restores beta-cell activity   BD is a 34-year-old patient admitted with an overdose of promethazine and  alcohol withdrawal symptoms. Patient has a history of alcohol abuse.   Q4 A drug that can be used in alcohol withdrawal is:   MB is a 58-year-old woman who presents with a prescription for simvastatin  10 mg daily. Her current medication is atenolol 50 mg daily. MB suffered a heart  attack last year.   GD is a 72-year-old female whose current medication is:  aspirin 75 mg daily  dipyridamole 100 mg tds  timotol 0.5% both eyes 2 drops bd  lactulose 20 ml daily   1 □ dose needs to be reviewed as the maximum adult daily dose   2 □ should not be used for more than 5 days   SP is a 64-year-old patient who is admitted to hospital with tiredness, shortness of  breath and ankle oedema. She has a medical history of congestive heart failure.  SP was intolerant to enalapril owing to the development of a cough. Her  medications on admission are:  spironolactone 12.5 mg daily  losartan 25 mg daily   2 □ exhibits a lower incidence of cough as a side-effect    LB is a 55-year-old male patient who developed vesicles unilaterally around his  waist. LB complained of a stabbing irritation in the area. LB is prescribed aciclovir  800 mg five times daily for 5 days.   AD is a 39-year-old female with bacterial endocarditis. She is started on  gentamicin 80 mg iv twice daily and penicillin G iv 1 .8 g every 6 h.   Q59 Penicillin G is available in 600 mg vials. How many vials are required  for each dose?   3 Q therapy may be changed to oral administration when the    Patient developed a rash and started complaining of generalised itch after the  administration of the drugs.   JZ is a 78-year-old obese male who is diagnosed with an acute attack of gout.   PMH hypertension, heart failure  DH enalapril tablets 5 mg daily  atenolol tablets 1 00 mg daily  bendroflumethiazide tablets 5 mg daily  aspirin ec tablets 75 mg daily   He is started on colchicine tablets 500 pg twice daily for six days.   A □ may be due to excessive production of uric acid   B □ may be due to increased renal elimination of uric acid   C □ results in the deposition of crystals of xanthine in the joints  D □ is characterised by excessive calcium deposited in the joints   2 □ requires confirmation of urate crystals in the synovial fluid of   1 □ should be used when there is a contraindication to NSAIDs   3 □ occurrence of diarrhoea and vomiting are used as an index   1 □ should be started 2-3 weeks after the acute attack has   HG is a 71 -year-old female with a history of Sjogren's syndrome. She presents  with complaints of dry eyes and dry mouth.   At the time the patient was on aspirin 1 50 mg daily, dipyridamole 25 mg tds,  glimepiride 1 mg daily and atenolol 100 mg daily. Recently hypothyroidism was  diagnosed and she was started on thyroxine 50 pg daily. During a recent follow  up, her diabetologist added metformin 500 mg daily because her blood glucose  level was 1 3.8 mmol/l. She was also started on simvastatin 10 mg nocte.   Her ESR is 1 09 mm/h and she has a positive rheumatoid factor.   Methylcellulose eye drops to be used as required are recommended to HG.   Q75 In view of the recent amendments to her treatment, HG should be  advised to:   2 □ concentration is used as the main diagnostic marker for    Interpretation of clinical laboratory tests is useful during diagnosis and during  therapeutic monitoring. Common laboratory tests include electrolytes, haema-  tology, renal function tests and liver function tests. In interpreting clinical  laboratory tests, it is important to use different tests to corroborate information  because laboratory errors are not uncommon, caused by, for example, spoiled  specimens, incorrect amount of specimen and medications that could interfere  with test results. Furthermore, laboratory investigations are best collaborated  through supporting clinical evidence. When possible laboratory results are  best evaluated in an holistic approach.   The mean corpuscular haemoglobin concentration (MCHC) is a red cell index  that forms part of haematology tests. It measures the average concentration  of haemoglobin in erythrocytes (red blood cells). It is decreased in different  presentations of anaemia, including iron deficiency anaemia and in thalas-  semia. In iron deficiency anaemia, the haematocrit value (space occupied by  packed erythrocytes) is decreased.   The measurement of total and differential white blood cell (WBC) count is a  part of all routine laboratory diagnostic evaluations. It is helpful in the evalu-  ation of a patient with an infection, although a high WBC count may also be  found in other conditions such as neoplasma, allergy and immunosuppression.  One type of WBCs is the lymphocytes, their primary function being to fight  chronic bacterial infection and acute viral infections. Lymphocytes can be    further classified into B cells and T cells. The mature B cells produce immuno-  globulins. The T cells have cell-mediated immunity as a major property, where  they act directly to eliminate certain microorganisms and regulate the activity  of B cells in producing immunoglobulins. An increased number of lymphocytes  (lymphocytosis) occurs with viral infections, such as in patients with upper  respiratory tract infections, mumps and infectious mononucleosis.   Thrombocytes (platelets) are elements in blood, their main role being the  maintenance of vascular integrity. In idiopathic thrombocytopenia purpura  there is a deficiency of platelets leading to bruising and bleeding. Idiopathic  thrombocytopenia purpura is associated with the occurrence of antibodies to  platelets.    When approaching therapeutic management of a patient, it is essential to  familiarise yourself with background information on the disease state(s) and  on the patient's presenting complaints.   Myopathy is a condition affecting the skeletal muscle, and which is manifested  by muscle weakness and wasting. Histological changes occur in the muscle  tissues, similar to those that occur in muscular dystrophies.   Tachypnoea is an abnormally fast breathing rate. It is characteristic of  respiratory diseases and occurs in hyperpyrexia. It occurs as a result of over-  activity at the level of the sympathetic nervous system.   Dysphasia (aphasia) is a condition resulting in impairment of the language  aspect of speech. It usually occurs as a result of cerebral cortex injury, such  as after surgery for a brain tumour or after a cerebral stroke. The presence of  dysphasia is frequently accompanied by writing disorders.   Prednisolone is a corticosteroid with a predominantly glucocorticoid activity.  However, owing to minor mineralcorticoid activity, it may still cause electrolyte  imbalance, namely sodium and water retention and potassium loss. Salbuta-  mol and propranolol do not interfere with plasma sodium electrolyte levels.  Salbutamol may precipitate hypokalaemia, especially with parenteral adminis-  tration or after nebulisation. The risk of hypokalaemia with salbutamol therapy  may be increased with concomitant administration of certain drugs, such as  corticosteroids and diuretics.   Paget's disease, neuropathy and haemophilia are all conditions that are  associated with the occurrence of muscular or joint pain. Paget's disease is a  disease of the bone where there is excessive bone destruction and abnormal-  ities in bone repair. The condition may be associated with bone pain, bone  deformity, fractures and pain caused by pressure on nerves. However, Paget's  disease may be asymptomatic. Neuropathy is a condition where there is  inflammation or degeneration of the peripheral nerves. It may occur as a  complication of long-standing uncontrolled diabetes. Patients complain of  excruciating pain in the peripheries. In haemophilia there is a deficiency of  one of the factors necessary for blood coagulation. Patients with haemophilia  are prone to develop bleeding in joints, resulting in pain.   Several persistent unexplained symptoms may indicate neoplastic disease and  would require further assessment to understand the underlying pathology.  Symptoms such as skin ulceration, unexplained fractures and general debility  may indicate neoplastic disease. Skin ulceration could occur as a result of skin  carcinoma. Unexplained fractures may be due to carcinoma involving the  bone structure. This tumour usually occurs as a secondary tumour to a solid  tumour that has originated in another area. General debility may be a  characteristic of malignant disorders, such as chronic myelocytic leukaemia,  Hodgkin's disease, non-Hodgkin's lymphoma and various solid tumours.   The administration of cytotoxic chemotherapy regimen may fail to achieve  remission in an individual patient compared with a cohort of patients owing  to drug resistance. Tumour cells may be inherently resistant or acquire resist-  ance after a number of treatment sessions. Tumour cell resistance may be  explained by a reduction of intracellular drug concentration, enzymatic  deactivation of the drug, and by increased repair of damaged DNA. If the  drugs fail to penetrate the solid tumour, then they are not in a position to  achieve cell death.   In Parkinson's disease patients have problems with postural stability, movement  and verbal communication. The involvement of physiotherapists and speech  therapists helps the patient to cope with the loss of mobility, to retain activity  as much as possible and to keep communication with carers. Patients with  Parkinson's disease have a mask-like expression, a monotonous voice and may  experience fatigue, drooling of saliva, dysphagia, constipation, excessive  swelling, speech and depressive disorders. Severe chronic pain is not a  presentation that is related to the occurrence of Parkinson's disease.   Ultrasound scanning is a non-invasive, non-toxic diagnostic procedure that can  be used to examine internal organs. It does not involve radiation. It is based  on sound waves that travel through the body tissues at different speed  depending on the density and elasticity of the organ tissues. Ultrasound  scanning is used to diagnose conditions such as tumours in areas such as  abdomen, heart, liver and kidneys. It is also used to assess the development  of the fetus.   Creatinine clearance is the rate of removal of creatinine from the body by the  kidney during glomerular filtration. It gives a measure of the glomerular filtra-  tion rate (GFR). The measured creatinine clearance is more accurate in the  assessment of renal function compared with the calculated creatinine  clearance, which is based on a formula where the serum creatinine concen-  tration is used. To measure the creatinine clearance, a 24-h urine collection  and a serum sample are required.   Isosorbide dinitrate is a nitrate that is a more stable preparation compared  with glyceryl trinitrate. Isosorbide dinitrate tablets are stable and do not require  special storage conditions. It is used in the prophylaxis and treatment of  angina and in left ventricular failure. The most common side-effect that may  occur is throbbing headache. Occurrence of this side-effect usually decreases  after a few days. The headache is associated with peripheral vasodilation.  Tolerance to the peripheral effects occurs early on in treatment.   Adrenaline is a potent sympathomimetic agent that is used in cardiac arrest  by intravenous injection preferably through a central line. It is the first-line    treatment in anaphylaxis, where it is usually given intramuscularly. Stimulation  of the alpha-adrenergic receptors produces vasoconstriction that may result in  hypertension. Blood pressure should be monitored during administration of  adrenaline. It should be used with caution in patients with hypertension. Over-  dosage may cause a sharp rise in blood pressure.   Methadone is an opioid agonist that is itself addictive and is used in the  management of patients who are physically dependent on opioids. Its  advantage in the management of opioid dependence is that it is administered  as a single daily dose, usually as an oral solution.   Tamoxifen is an oestrogen-receptor antagonist that is used for breast cancer  and anovulatory infertility. Its side-effects are very similar to the menopausal  phase and hot flushes are a common side-effect. Suppression of menstruation  may occur in premenopausal women. As the use of tamoxifen is associated  with an increased risk of endometrial changes, including hyperplasia, polyps,  cancer and uterine sarcoma, occurrence of menstrual abnormalities, including  abnormal vaginal bleeding and vaginal discharge, warrant immediate investi-  gation. Hence patients receiving tamoxifen should be advised that if menstrual  irregularities occur they should seek medical advice. Tamoxifen can increase  the risk of thromboembolism, and therefore patients should be advised about  the symptoms that may indicate onset of thromboembolism, such as sudden  breathlessness and pain in the calf, so that they seek advice immediately.   Sodium bicarbonate as a parenteral preparation for fluid and electrolyte  imbalance is used in severe metabolic acidosis, for example, in renal failure  when blood pH is less than 7.1. By administering sodium bicarbonate, in    conjunction with sodium chloride when there is also sodium depletion, pH of  blood is increased. Sodium bicarbonate may also alkalinise the urine, which  will increase the excretion of weak acids. In hypomagnesaemia, magnesium  sulphate intravenous infusion is administered.   Phytomenadione is vitamin K1 . Vitamin K is a fat-soluble vitamin that is  required for the hepatic synthesis of prothrombin and other blood clotting  factors (factors VII, IX, X and proteins C and S). Neonates are particularly  prone to develop vitamin K deficiency and this may lead to haemorrhagic  disease including intracranial bleeding. It may be used in babies at birth as  a single intramuscular injection to prevent vitamin K deficiency bleeding.  Vitamin K deficiency may occur in underweight neonates owing to inadequate  synthesis.   Enoxaparin is a low-molecular-weight heparin that has a longer duration of  action when compared with unfractionated heparin. The dose for enoxaparin  varies from the dose for heparin; for example, in the prophylaxis of deep vein  thrombosis before surgery, 2000 units of enoxaparin are administered 2 hours  before surgery, whereas for heparin 5000 units are administered 2 hours  before surgery. As with heparin, thrombocytopenia may occur with the  administration of low molecular weight heparins. Enoxaparin should be  avoided in patients who have developed thrombocytopenia with heparin.  Regular monitoring is required when the patient is also taking any drugs that  interfere with haemostasis. The use of oral anticoagulants, dipyridamole,  aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) should be  reviewed. Care should be taken when used in conjunction with thrombolytic  enzymes and high doses of penicillins and cephalosporins.   Isotretinoin is a retinoid that may be used orally in the specialist management  of severe acne vulgaris. Retinoids have many contraindications and serious  side-effects. Isotretinoin is teratogenic and therefore women of child-bearing  age should be advised to avoid pregnancy and to practise effective contra-  ception. Retinoids should only be used in premenopausal women if they have  severe disabling skin disease that is resistant to other treatment and if  pregnancy has been excluded. Treatment with oral isotretinoin should be  started only during the second or third day of a menstrual cycle and contra-  ceptive precautions should be continued for at least 4 weeks after the end of  treatment. Common side-effects of oral isotretinoin treatment include dryness  of the skin presenting with dermatitis, scaling, thinning, erythema and pruritus,  epidermal fragility and dryness of the lips, pharyngeal mucosa and nasal  mucosa. During treatment and for at least 6 months from stopping treatment,  patients should be advised to avoid wax epilation because of a risk of  epidermal stripping, and to avoid dermabrasion and laser skin treatment as  there is risk of scarring. Patients should be advised to avoid exposure to ultra-  violet light and to use sunscreens, emollients and lip balms regularly during  treatment.   Colonoscopy is a diagnostic procedure that is carried out to examine the colon  and terminal ileum. To aid the direct observation of the bowel, bowel cleansing  is required before the procedure. Patients are advised to follow a clear-liquid  diet before the procedure at least for one day. Bowel cleansing preparations  containing magnesium salts are administered orally on the day before the  procedure. They produce rapid evacuation of the bowels. Patient should not  consume any food or fluids from 6-8 hours before the procedure.   Patients with a history of asthma presenting with a chest infection should be  referred for assessment about the need to use antibacterial agents and the    necessity of reviewing asthma treatment. A paediatric patient is at a higher  risk of rapid deterioration. Patients who are using diuretics are more prone to  dehydration in a hot climate. If they present symptoms of a heat stroke they  should be referred for assessment of their medical condition, as they are at  higher risk of developing complications. Acute diarrhoea may be treated by  recommending oral rehydration salts. The patient is asked to contact a pharma-  cist, should the situation get worse or if it is not managed within a few days.   Helicobacter pylori , a Gram-negative bacterium, is implicated as a cause of  chronic gastritis and peptic ulceration. Its eradication in the stomach entails a  triple-therapy regimen that is based on a proton pump inhibitor such as  omeprazole, and two anti-infective agents, namely amoxicillin and either clari-  thromycin or metronidazole. In patients who are penicillin sensitive, the triple  therapy regimen considered consists of a proton pump inhibitor, clarithromycin  and metronidazole. Telithromycin is a derivative of erythromycin that is not  used in Helicobacter pylori eradication therapy.   In patients affected by the human immunodeficiency virus (HIV), the aim of  treatment is to decrease the plasma viral load as much as possible for the  longest possible time. Before starting treatment or when changing drug  therapy, viral sensitivity to antiretroviral agents should be established. The  onset of drug resistance is reduced by using combination of drugs so as to  have a synergistic or additive effect. Care should be taken to ensure that the  combination used does not have an additive toxicity as antiretrovirals are  toxic. Common combinations include two nucleoside reverse transcriptase  inhibitors and either an HIV-protease inhibitor or a non-nucleoside reverse  transcriptase inhibitor. In HIV, viral replication leading to accumulation of  mutations results in the emergence of drug-resistant variants and consequently  disease progression.   Diabetic ketoacidosis is a condition where there is acidosis and an accumu-  lation of ketones in the body resulting from extensive breakdown of fat. It  occurs in patients with hyperglycaemia and ketosis as a result of insulin  deficiency. Normally diabetic patients with hyperglycaemia do not progress  to diabetic ketoacidosis. Factors that could precipitate the condition include  infection, dehydration, surgery, sustained strenuous exercise, trauma. Patients  with diabetic ketoacidosis present with a fruity odour of acetone on the breath,  mental confusion, dyspnoea, nausea, vomiting, and dehydration. The  condition may lead to coma. Retinopathy is a complication of diabetes that  could lead to blindness.    Pulmonary oedema may result from the failure of a number of homeostatic  mechanisms and it is a condition that can develop acutely and can be fatal.  It most commonly occurs as a result of chronic heart failure. Diuretics provide  a dramatic improvement of the condition.   Signs and symptoms of pulmonary oedema include dyspnoea, cough, orthop-  noea, and tachypnoea. Owing to the accumulation of extravascular fluid in  lung tissues, alveoli and in the extremities, the patient may present with an  increase in weight.   An acute attack of pulmonary oedema may develop due to progressive heart  failure or when the patient is not compliant with medication, particularly the  diuretic therapy. It may also occur due to hypervolaemia, such as when  compromised and non-compromised patients are exposed to an excessive fluid    infusion rate or to a high sodium intake. Conditions that lead to an increased  metabolic demand, such as high fever and hyperthyroidism, may also precipi-  tate acute pulmonary oedema.   Metolazone is a diuretic that is associated with profound diuresis, especially  when it is combined with a loop diuretic. Patients receiving metolazone should  be monitored for electrolyte imbalance and outcome of therapy may be  assessed by measuring change in body weight and urine production.   Metolazone is a diuretic with actions similar to a thiazide diuretic, and  bumetanide is a loop diuretic. Metolazone has a long duration of action of  about 12-24 h compared with intravenous bumetanide, which has a duration  of action of 0.5-1 h. Diuretics increase diuresis and result in a reduction of  blood volume.   Once PS is stabilised, a long-term therapeutic plan should be carried out.  Metolazone treatment should be withdrawn, after which a change from  bumetanide to oral therapy should be attempted. The patient should be  advised about the importance of compliance with bumetanide, and that the  unwanted effect of increased diuresis with oral treatment usually decreases  with time. The patient should be advised to take the drug in the morning.  Potassium levels should be monitored and, if the patient is not taking any  drugs with a potassium-sparing effect, then potassium supplements should  be considered when bumetanide therapy is given long-term.    CA is a diabetic patient whose blood glucose level needs monitoring. Upon  discharge the pharmacist needs to advise the patient on her condition and on  her medication so as to avoid future deterioration. She is showing signs of  dehydration and uncontrolled blood glucose levels.   Rehydration and control of hyperglycaemia are the primary aims. Her skin  condition is a secondary complication of uncontrolled diabetes. The anti-  bacterial agent is continued and patient is started on an antidiabetic drug  (glibenclamide) to control blood glucose levels. CA is also administered  haloperidol (an antipsychotic).   In patients who are dehydrated, urine output is very much decreased. The  extent of rehydration, which is being undertaken using intravenous infusion of  sodium chloride, should be assessed by monitoring urine output. Regular blood  glucose monitoring is required and, if necessary, antidiabetic therapy should  be reviewed.   Clinical features of hyperglycaemia include thirst, dry mouth, reduced skin  turgor, polyuria, nocturia. A diabetic complication is an increased suscepti-  bility to infection especially in the skin, vaginal area and peripheries.   Ciprofloxacin may be administered at a dose of 500 mg orally twice daily.  As CA has been started on this antibacterial agent only the day before her    admission, there is no indication that warrants a need to increase the dose  or review the therapy because the drug is ineffective. The sodium chloride  infusion is required to rehydrate the patient, and should be continued until  normal urine flow is achieved. The pharmacist could monitor the patient's  progress and advise the prescribing team when to withdraw the infusion. There  is no apparent rationale for the use of haloperidol in this elderly patient. Her  state of confusion is due to her hyperglycaemic state, which has precipitated  dehydration. Correction of these complications should improve her confusion.  Haloperidol has a rapid effect on hyperactive states and initial doses may help  to calm down the patient. However, continued use may precipitate hypo-  glycaemia. Continued treatment with haloperidol should be reviewed.   Glibenclamide and gliclazide are oral sulphonylureas that are used in  diabetes to augment secretion of insulin. They are effective only in patients  with residual pancreatic beta-cell activity. Gliclazide is a shorter-acting  product. It has a duration of action of about 12 h whereas glibenclamide has  a duration of action of up to 24 h. The shorter-acting product is less likely to  cause hypoglycaemia. CA is an elderly patient, who may present with a  slower metabolism of the drug; she may be living alone and may have  problems with maintaining regular meals. The dose of glibenclamide for  elderly patients is usually 2.5 mg after breakfast.   CA should be advised to consume small, frequent regular meals that are low  in fat and carbohydrate content. She should be educated on the foods to  include in her diet and about the importance of having a regular schedule of  food intake to avoid hypoglycaemic attacks. She should be reminded that she  has to continue taking the glibenclamide tablet daily at breakfast to avoid  recurrence of hyperglycaemia.   Hypoglycaemia with sulphonylureas may occur either because of excessive  closes or skipped meals. If CA continues to take her glibenclamide tablets and  she skips meals, there is a higher risk of hypoglycaemia.    Alcohol is a central nervous system depressant. Conditions that are associated  with alcoholism include liver disease, cardiomyopathy, pancreatitis and gastro-  intestinal disease. Signs and symptoms of alcohol withdrawal include tremor,  tachycardia, diaphoresis, labile blood pressure, anxiety, nausea and vomiting,  hallucinations and seizures.   Promethazine is a sedating antihistamine, which BD was probably using  initially for the insomnia and sleep disorders that are associated with alcohol  withdrawal syndrome. Side-effects that could occur with the use of pro-  methazine, especially in overdosage include drowsiness, headache, and  antimuscarinic effects such as blurred vision and urinary retention.   Promethazine is a sedating antihistamine that could be used in the symptom-  atic relief of allergy of nasal or dermatological origin, as a hypnotic and in  motion sickness. It can be used in adults and children over 2 years.   Long-acting benzodiazepines such as diazepam could be used in alcohol  withdrawal to counteract the withdrawal symptoms. In alcohol withdrawal,    symptoms of the initial phases do not necessarily diminish as withdrawal  advances. This depends on the amount of alcohol consumed, on the abrupt-  ness of discontinuation and on the patient's general well-being. When the  patient is started on a benzodiazepine, advice on alcohol abstinence should  be provided. Also the patient should be referred to patient-support groups, to  provide the necessary psychosocial support for the management of alcohol  abuse.    A myocardial infarction, also referred to as a heart attack, is the necrosis of  a portion of the cardiac muscle and occurs due to occlusion of the coronary  artery, either because of atherosclerosis or thrombus or a spasm. The patient  presents with a crushing chest pain that may radiate to the left arm, neck and  epigastrium. Statins are used as lipid-lowering agents in conjunction with diet  to reduce total cholesterol and low-density-lipoprotein cholesterol as a  secondary prevention of the recurrence of cardiovascular disease. They reduce  morbidity and mortality in these patients.   Simvastatin is a statin and it may cause rare but significant side-effects of  myalgia, myositis and myopathy. Patient should be advised to report any  muscle pain, tenderness and weakness as they could be signs of these side-  effects. Higher efficacy has been shown with the administration of simvastatin  at night, compared with in the morning, probably because cholesterol bio-  synthesis reaches a peak during the night.    Common side-effects associated with statins include headache, gastrointestinal  symptoms and altered liver function tests.   The use of lipid-regulating drugs, including statins, should be combined with  a low-fat diet and moderate exercise such as walking so as to reduce the risk  of cardiovascular disease.    Medication review, particularly for elderly patients, is useful to evaluate  rationale for drug therapy, to monitor outcomes, to identify problems with the  medications and to re-inforce patient counselling. GD is receiving dipyri-  damole and aspirin as antiplatelet drugs; timotol, a beta-blocker; and  lactulose, an osmotic laxative.   Dipyridamole is used as an oral preparation for the prophylaxis of thrombo-  embolism and for the secondary prevention of ischaemic stroke and transient  ischaemic attacks. It may cause increased bleeding during or after surgery  and it may induce bleeding in patients receiving oral anticoagulants without  altering the prothrombin time. It may be used in combination with low-dose  aspirin as this combination may further reduce the risk of ischaemia.   Lactulose is a semi-synthetic disaccharide that can be safely used on a long-  term basis in elderly patients to maintain regular bowel evacuation, especially  in patients with limited mobility. The initial adult dose of lactulose is 15 ml  twice daily and this may be adjusted according to the individual's needs.  Therefore 20 ml daily dose is an acceptable dosage regimen.   GD is receiving prophylactic therapy for secondary prevention of cerebro-  vascular and cardiovascular disease, timotol for glaucoma and lactulose to  maintain regular bowel movements.    SP is presenting with a deterioration of congestive heart failure presenting  mainly as oedema. Management of congestive heart failure may include an  angiotensin-converting enzyme inhibitor (ACE) such as enalapril, a diuretic if  there is fluid overload, spironolactone, beta-blockers and digoxin.   SP is presenting the classic symptoms of heart failure, namely tiredness,  shortness of breath and oedema. In SP the aims are to control the symptoms  of heart failure and limit the deterioration of the condition leading to oedema.   Spironolactone is a potassium-sparing diuretic that acts by antagonising aldos-  terone. It can be used in patients already receiving an ACE inhibitor to reduce  the symptoms and mortality associated with congestive heart failure. Low  doses of spironolactone are used and the maximum dose is 25 mg daily.   In patients with congestive heart failure receiving spironolactone, the moni-  toring of serum creatinine and potassium is necessary. Spironolactone should  not be used in patients with hyperkalaemia or in severe renal impairment.   Losartan is an angiotensin-ll receptor antagonist which may be used as an  alternative to ACE inhibitors in patients who develop cough. The usual main-  tenance dose for losartan is 50 mg daily.   Digoxin is a cardiac glycoside that may be used in patients with heart failure  when there is atrial fibrillation. It is a positive inotropic drug and it increases  contractility of the heart thus increasing cardiac output. It has a long halflife.   Digoxin has a narrow therapeutic margin and treatment may lead to digitalis  toxicity, which may be manifested by nausea, vomiting, anorexia, diarrhoea  and abdominal pain. This may progress to cardiac toxicity resulting in heart  block. Hypokalaemia in patients receiving digoxin increases risk of digitalis  toxicity. It is necessary to monitor plasma potassium levels and plasma digoxin  concentrations. In patients who are already receiving spironolactone or an  ACE inhibitor, risk of hypokalaemia is minimal.    LB has herpes zoster infection, also known as shingles. Antiviral treatment  reduces the severity and duration of pain, reduces complications and reduces  viral shedding. Complications of shingles include postherpetic neuralgia which  lasts months to years, eye or ear involvement. Treatment with antiviral drugs  should be started within 72 h of the onset of the rash.   LB has herpes zoster infection. It is an acute infection due to re-activation of  the varicella zoster virus which is latent in the body. It affects mainly adults  and is characterised by the development of painful vesicles that follow the  underlying route of a nerve. The vesicles are usually unilaterally distributed  over the body.   The patient should be advised to take aciclovir tablets at regular intervals and  to complete the prescribed course. The patient should be advised to avoid  exposure to sunlight, as aciclovir may cause photosensitivity.   Gastrointestinal side-effects of aciclovir include nausea, vomiting, abdominal  pain and diarrhoea. Other side-effects are headache, fatigue, rash, urticaria  and pruritus.   Calamine lotion may be used by LB to reduce itching and to provide symptom-  atic relief of the pain. Amitriptyline may be used as an adjuvant analgesic,  particularly if the patient develops postherpetic neuralgia. In addition an  analgesic such as a non-steroidal product and a topical corticosteroid to  reduce severe inflammation may be considered.   Bacterial endocarditis is an infective condition affecting the endocardium and  the cardiac valves. It is more common when there are cardiac abnormalities    such as aortic valve disease, pulmonary stenosis and mitral stenosis or in the  presence of prosthetic valves. In infective endocarditis, it is essential to identify  causative organism, to eradicate the organism and to prevent recurrence of  infection. It usually occurs when bacteria are released from an infected site  such as a tooth or skin abscess or after a surgical intervention.   Each vial contains 0.6 g and therefore for a dose of 1.8 g, three vials are  required.   Penicillin G, as with all penicillins, is a bactericidal and acts by interfering  with bacterial cell-wall synthesis. Penicillin G is inactivated by bacterial beta-  lactamases. As it is inactivated by gastric acid, and absorption from the gut  is very low, it is administered as an intramuscular injection or by slow intra-  venous injection or by infusion.   Gentamicin is an aminoglycoside that has a bactericidal action against Gram-  negative and Gram-positive bacteria. It is excreted primarily by the kidneys,  so in renal impairment, the dose should be reduced or the dosing intervals  increased. Aminoglycosides are not absorbed from the gastrointestinal tract,  and therefore for a systemic effect, parenteral administration is required.   Hypersensitivity to antibacterial agents and the development of a heat rash  are possible.   The clinical presentation of bacterial endocarditis varies. Usually there is an  insidious onset and the patient's condition starts to deteriorate gradually. Fever  is the most common finding, usually occurring at a relatively low grade. Initial  symptoms are fatigue, low-grade fever, weakness, anorexia and weight loss.  Embolic phenomena such as splenic or renal infarction and skin manifesta-  tions occur in a large number of cases. Peripheral manifestations of endocardi-  tis may occur, such as petechiae and finger clubbing. In some patients signs  of renal failure are also manifested.    JZ presents with an acute attack of gout. He is on medication to control his  hypertension and heart failure. He is taking an angiotensin-converting enzyme  inhibitor (enalapril), a beta-adrenoceptor blocker (atenolol), a thiazide diuretic  (bendroflumethiazide) and aspirin as an antiplatelet agent to prevent occur-  rence of cerebrovascular disease and myocardial infarction.   Gout is a condition associated with either an increased production of uric acid  or a decreased excretion of uric acid. Excess uric acid in the body is converted  to sodium urate crystals that are deposited in joints, most commonly in the big  toe. Increased levels of serum uric acid may be due to excessive production  of uric acid or to excessive destruction of cells and therefore breakdown of  nucleic acids, resulting in the production of uric acid.   Heart failure is a condition that may increase risk of hyperuricaemia. Diuretics  interfere with the excretion of uric acid and alter the concentration of uric acid  in blood. This results in precipitation of uric acid salts from the blood which  become deposited in the joints. A diet that consists of excessive consumption  of purine-rich food such as meat and organ meat increases production of uric  acid.   An acute attack of gout is characterised by a rapid onset of pain, swelling  and inflammation usually affecting the first metatarsophalangeal joint in the  big toe. Initially, the attack is monoarticular but it may progress to include other  joints. Attacks could recur with no clear provocation.   The clinical signs are so characteristic of the condition that diagnosis could be  based on their presentation. Concentration of urate crystals in the synovial  fluid of joints correlates very closely with serum levels. Serum uric acid levels  may be measured, particulary to monitor treatment. Hyperuricaemia also tends  to be present in other arthritic disease states. The erythrocyte sedimentation  rate (ESR) is a non-specific test that indicates occurrence of infection or inflam-  matory diseases. As it is a non-specific test, its relevance to the diagnosis of  gout is minimal.   JZ should be advised to rest the affected joint, maintain good fluid intake and  to take the prescribed drug. The use of colchicine in older people may precipi-  tate dehydration and electrolyte imbalance because of the common occurrence    of nausea, vomiting and diarrhoea as side-effects. JZ should be advised to  report side-effects immediately.   Colchicine is an effective drug, which is used in the acute management of gout  or for short-term prophylaxis during initial therapy with allopurinol or other  uricosuric agents. Its use is limited by the occurrence of side-effects, especially  at high doses or in patients with renal or hepatic disease. It produces a  dramatic response in acute gout probably by acting as an antimitotic and  inhibiting leucocyte mobility to the inflamed areas.   Usually non-steroidal anti-inflammatory drugs are used as first-line treatment in  the management of acute attacks of gout. They counteract the pain and reduce  the inflammation. JZ suffers from heart failure and colchicine is preferred to  avoid the fluid retention that may occur with NSAIDs. Also, NSAIDs may  interact with the medications that JZ is taking, namely the diuretics and anti-  hypertensive agents, causing a decrease in the hypotensive effect. Although  this interaction is usually not of clinical significance, it is worth considering  other therapeutic options. The disadvantage of colchicine is that it is commonly  associated with side-effects, particularly signs of gastrointestinal toxicity mani-  fested as diarrhoea and vomiting. Occurrence of these side-effects indicates  that the dose should be reviewed. Colchicine is associated with cumulative  toxicity and diarrhoea, nausea, vomiting and abdominal pain are the first  signs of toxicity. The dose should be stopped or reduced depending on the  patient's symptoms.    Non-steroidal drugs such as indometacin and diclofenac are considered in the  management of acute attacks of gout. Aspirin and its derivatives should be    avoided during an acute attack as these agents compete with uric acid for  excretion and may worsen rather than decrease the symptoms. In fact it is  worth considering stopping the aspirin 75 mg daily dose until the acute attack  subsides. The dose is relatively low but the patient already has other factors  that may be contributing to the condition and the aspirin is used as a prophyl-  actic agent in JZ.   Obesity, heart failure and drug therapy are all factors in JZ which increase  susceptibility to gout. JZ should be advised on how to counteract the factors  that may be corrected. He should be advised to lose weight, which will help  him to manage his cardiovascular risk better, as well as to decrease the recur-  rence of gout. He should be advised to take regular exercise that is not very  strenuous, such as short walks and to follow a healthy diet that is based on  fruit and vegetables, which will be low in purines.   Allopurinol is used for the long-term prophylaxis of gout and is considered  for patients who have a high incidence of recurrence. It reduces uric acid  production by inhibiting the enzyme xanthine oxidase, which brings about  the oxidation of hypoxanthine to xanthine and of xanthine to uric acid. As  allopurinol may prolong an attack or precipitate it, it should not be started  during an acute attack. It should be started 2-3 weeks after the acute attack  has subsided. It is given in a once-daily dose. It has an active metabolite,  oxipurinol, which has a plasma halflife of 15 or more hours.   Uricosuric drugs include sulfinpyrazone and probenecid. Like allopurinol, they  may be used as prophylactic agents. They should be avoided in patients with  overproduction of uric acid and are ineffective in patients with poor renal    function. They inhibit the renal tubular re-absorption of uric acid and therefore  increase urinary excretion of uric acid. Patients should be advised to consume  a good fluid intake of at least two litres a day. This will decrease the risk of  uric acid stone formation.    HG suffers from Sjogren's syndrome, a condition that is frequently associated  with rheumatoid arthritis and Raynaud's phenomenon. The condition presents  with a deficient moisture production of the lacrimal, salivary and other glands  resulting in dryness of the mouth, eyes and other mucous membranes. The  patient may also have the classic characteristics of rheumatoid arthritis. HG  is a diabetic and is taking a sulphonylurea (glimepiride) and a biguanide  (metformin). She is on a beta-blocker (atenolol) and an antiplatelet drug (dipyri-  damole) indicating possibility of a history of cardiovascular disease. She is  taking simvastatin as a lipid-regulating drug. HG has recently been diagnosed  with hypothyroidism and she was prescribed thyroxine. Her ESR is elevated  (>30 mm/h) and she is seropositive for rheumatoid factor.   Thyroxine, levothyroxine, is a thyroid hormone used in hypothyroidism.  Because it increases metabolic rate, it should be taken in the morning to  minimise the occurrence of insomnia. Common side-effects of metformin are  gastrointestinal, such as nausea and vomiting. By taking the tablet with or after  food, these side-effects are minimised. Dipyridamole should be taken three  times daily before food, as dipyridamole is incompletely absorbed from the  gastrointestinal tract.   Hypothyroidism occurs in the older population and may have an insidious  onset. Signs and symptoms of hypothyroidism tend to be subacute and presen-  tation may be related to non-specific symptoms.   When thyroxine is administered to patients receiving warfarin, it enhances the  anticoagulant effect of warfarin.   Caution should be undertaken when thyroxine is started in elderly patients and  in patients with cardiovascular disorders, as there could be a rapid increase  in metabolic rate leading to problems including anginal pain, arrhythmias,  palpitations, tachycardia. In diabetic patients, caution should be used, as its  introduction may interfere with antidiabetic therapy. It should be started in  small doses at small increments.   Side-effects resemble symptoms of hyperthyroidism and include diarrhoea,  anginal pain, tachycardia, skeletal muscle cramps, tremors, restlessness,  excitability, insomnia, headache and flushing.   The thyroid hormones T3 and T4 are transported in the blood by three proteins:  the thyroid-binding globulin; thyroid-binding prealbumin; and albumin. Hence  the total thyroid hormones concentration in plasma changes with alterations  in amount of thyroxine-binding in plasma. Only the unbound thyroid hormone  is able to diffuse into the thyroid cell and elicit a biological response. For this  reason the concentration of total thyroid hormones in plasma is not considered  a good diagnostic marker. Laboratory investigations to diagnose and monitor  management of hypothyroidism are based on free T3, free T4 and thyroid-stimu-  lating hormone (TSH). In the early stages of hypothyroidism, free T 3 and free  T4 concentrations may be normal and a modest increase in TSH is detected.  Free T 3 and free T 4 may decline as the disease progresses.   headings followed by a list of numbered questions. For each  numbered question select the one heading that is most closely  related to it. Each heading may be used once, more than once,  or not at all.   Q1 is a description of conditions that the patient has experienced previously  Q2 is symptoms presented by the patient  Q3 is the findings of examination of the patient    Directions: For each of the questions below, ONE or MORE of the   responses is (are) correct. Decide which of the responses is  (are) correct. Then choose:    A □ if 1 , 2 and 3 are correct  B □ if 1 and 2 only are correct   2 □ should not be performed in periods of less than five years   1 □ is carried out to confirm the occurrence of cardiovascular    Q1 ' Patients with angina pectoris may be advised that factors which precipi-   3 □ any signs of infection should be reported to a health   Q19 When a patient presents with a fall and a blackout:   3 □ the incident should raise the alarm only if it occurs in   Q23 Diabetic patients should be advised to monitor their condition because  they are prone to develop:   Q25 Disadvantages of the administration of corticosteroids in the eye include:   1 □ an asthmatic patient who presents with fever, chesty cough   patient profile and answer the questions. For questions with  one or more correct answers, follow the key given with each  question. For the other questions, only one answer is correct  - give the corresponding answer.   PMH diabetes mellitus controlled by diet  hypertension  congestive heart failure  DH bumetanide 1 mg daily   potassium chloride 600 mg bd  isosorbide dinitrate 10 mg tds  atenolol 100 mg bd  aspirin 75 mg daily  lorazepam 1 mg tds  metoclopramide 10 mg prn  PC increasing shortness of breath   dyspnoea, cyanosis, tachycardia  O/E BP 160/100 mmHg  pulse 1 00 bpm    Diagnosis congestive heart failure  Lab sodium 130mmol/l (135-145)  potassium 3.2 mmol/I (3. 5-5.0)  chloride 95 mmol/l (96-106)  fasting blood glucose 15.6 mmol/l (3. 6-6.0)   Drug treatment on discharge:  bumetanide 1 mg daily  isosorbide dinitrate 10 mg tds  enalapril 5 mg nocte  aspirin 75 mg daily  lorazepam 1 mg tds  metoclopramide 10 mg prn   Q37 The patient should be advised to take isosorbide dinitrate tablets at:    XY is a 49-year-old patient who is allergic to penicillin. She was prescribed  erythromycin for cellulitis. She developed a rash and erythromycin was withdrawn.    Q39 Which of the following antibacterial agents is the most appropriate for  XY:    PS is a 69-year-old patient who presents with orofacial unwanted movements. His  medication includes diazepam 5 mg nocte and amitriptyline 25 mg tds   QR is a 75-year-old male whose current medication is:  co-codamol 2 tablets qid  paracetamol 1 g qid  gliclazide 80 mg bd  ferrous sulphate 800 mg tds  dipyridamole 25 mg tds  isosorbide dinitrate 20 mg tds   3 □ reviewing the isosorbide dinitrate dose as the maximum  daily dose is 5 mg daily   MR is an 82-year-old female hospitalised at the ophthalmic ward. Her current  medication is:   framycetin eye drops 1 drop both eyes tds  dorzolamide eye drops 1 drop left eye bd  acetazolamide tablets 125 mg bd  timolol eye drops 0.5% 1 drop left eye bd  ranitidine tablets 150 mg nocte  bisacodyl tablets 5 mg daily    Q48 Use of bisacodyl in MR requires assessment because it can:   CB, a 59-year-old male was admitted to hospital with a severe chest infection. His  current medication is  lactulose 30 ml daily   warfarin 4 mg daily adjusted according to INR  paracetamol 500 mg prn   CB is allergic to penicillin and suffers from tinnitus and hearing loss.   JM is a 40-year-old female in the terminal stages of carcinoma. Her current  medication is:   paroxetine 20 mg daily  tamoxifen 20 mg daily  co-codamol 2 tabs tds  diazepam 2 mg nocte   Q55 What side-effects could be expected from analgesics used for palliative  care?   1 □ is used in JM to alleviate depression and anxiety   LX is an 82-year-old female who is admitted with an infection in the right toe. On  admission her medication is:  dipyridamole 100 mg tds  aspirin 75 mg daily  glibenclamide 5 mg bd    Her fasting blood glucose level was 12 mmol/l (3. 6-6.0 mmol/l). LX was started  on:   cefuroxime 750 mg iv 8 hourly  metronidazole 500 mg iv 8 hourly  insulin according to blood glucose levels   FS has been prescribed 50 mg morphine sulphate in the morning and 100 mg  morphine sulphate at night. The preferred route of administration for FS is oral  tablets and morphine sulphate is available as tablets of 10 mg, 30 mg, and  60 mg.    Q61 How many morphine sulphate tablets need to be dispensed for a   Q62 How many morphine sulphate tablets need to be dispensed for the  evening dose?   CP is a 28-year-old male who presents with complaints of weakness, dizziness and  sweating. CP had undergone a gastroscopy, which revealed a duodenal ulcer. He  tested negative to the Helicobacter pylori urea breath test. Laboratory tests confirm  that CP is found to have anaemia. His medication on admission is  gliclazide 40 mg daily  esomeprazole 20 mg daily   MC is an 84-year-old female referred to the A&E department with gradual  deterioration in her general condition. Patient is not eating or drinking for the past  few days.   digoxin 0.0625 mg daily  bumetanide 1 mg daily  metformin 500 mg bd  amitriptyline 20 mg nocte  ranitidine 150 mg daily  SH lives alone, ° smoking, ° alcohol   pressure sore over sacrum and heels  BP: 170/110 mmHg  pulse: 1 20 bpm   LaB WBC 8 X 10 9 /l (5-10 X 10 9 /l)   Patient is started on intravenous 0 . 9 % saline 1 litre, alternating with 5% dextrose  1 litre 8 hourly at the A&E department and admitted to hospital.   Q67 The poor health, poor respiratory effort and bilateral inspiratory  crackles suggest the need to start:    Q69 With regards to the use of metformin, MC should be advised:   3 □ that soft stools occur usually as a long-term side-effect   BC is a 9-year-old female who has been on holiday at a seaside resort for a week.  She presents with her parents and is complaining of a red, scaly skin area on both  her elbows. The area has a golden-yellow crust and BC complains that it is very  itchy. BC suffers from atopic eczema.    Q77 Drugs that could be recommended for use in BC include:   GM is a 28-year-old female who suffers from tension headache. She would like to  have a medication that is stronger than paracetamol.   Q80 The use of aspirin would not be recommended if GM:    Abbreviations are commonly encountered in case notes. They are standard-  ised to help exchange of information between different health care settings  and so that case notes can be used by different health professionals.   PMH stands for past medical history, where information on conditions experi-  enced previously by the patient is reported.   PC stands for presenting complaint, where the symptoms that are reported by  the patient are included.   O/E stands for on examination, where the information observed by health  professionals is noted.    Clinical laboratory tests are significant in chronic disease management to  monitor outcomes of therapy and compliance with pharmacotherapy and  lifestyle measures.   BUN stands for blood urea nitrogen. It provides an indirect measure of renal  function and glomerular filtration rate, and also gauges liver function. Urea is  formed in the liver as an end-product of protein metabolism. Urea is trans-  ported to the kidneys for excretion. For kidney function monitoring it should  not be used as a stand-alone test, because changes in the metabolic function  of the liver could affect the BUN results. BUN is used together with creatinine  levels in the monitoring of kidney function.   TSH stands for thyroid-stimulating hormone , and its concentrations are  monitored in thyroid disease.   HbAlc, also referred to as glycosylated haemoglobin, is used to monitor  diabetes. It measures the blood glucose bound to haemoglobin. As erythro-  cytes have a life span of 120 days, the test reflects the average blood sugar  level in the 2-3 months preceding the test. It gives an indication of the blood  glucose levels over the past 90 days.   INR stands for international normalised ratio. It is a ratio value comparing a  patient's prothrombin time against the prothrombin time of normal control  patients. It is used as a monitoring index in patients receiving warfarin. INR  levels for patients on warfarin are aimed at between two and three, depending  on the goal of treatment and other factors, such as recurrent deep vein  thrombosis or use of prosthetic heart valves.   Lung function tests involve the use of a spirometer to measure lung volumes  and air flow rates. Measurements include forced expiratory volume, vital  capacity, forced vital capacity and residual volume. Lung function tests are  used to determine the severity of the respiratory disease and to monitor  outcomes of therapy. Patients may be educated to use a patient-friendly  spirometer device to monitor their condition and adjust their therapy accord-  ingly as advised by the healthcare team. Lung function tests may be used to  determine the reversibility of airway disease. Sometimes a bronchodilator may  be administered before the procedure after baseline pulmonary function tests  have been carried out, to evaluate the degree of disease reversibility.   Heart failure results in a reduced cardiac output leading to impaired oxygena-  tion and a compromised blood supply to muscles. A common cause of heart  failure is left ventricular systolic dysfunction. Sustained heart failure results in  compensatory mechanisms by the body to maintain circulation. These result in  long-term sequelae such as remodelling of the left ventricle and cardiac  enlargement. A chest radiograph may reveal an enlarged cardiac shadow  and consolidation in the lungs. Due to the occurrence of cardiomegaly,  arrhythmias may occur. Patients with heart failure present with dyspnoea or  orthopnoea, may appear pale and may have cold extremities.   Colonoscopy is a diagnostic procedure that is used in the assessment of gastro-  intestinal disorders of the colon. It may be used to diagnose inflammatory  bowel disease and carcinoma. It is used to assess the management of patients  with inflammatory bowel disease; for example, in patients who have  undergone surgery for ulcerative colitis, regular colonoscopy is undertaken to  evaluate recurrence of the disease. It is also used as a diagnostic screening  tool in familial colon cancer. It may be repeated as necessary. A disadvantage    is that bowel cleansing is required before the procedure and if this is not done  efficiently then the results are compromised.   EEG stands for electroencephalography and it is a test carried out to measure  and record electrical impulses in the brain. It is used to diagnose seizures.  However the EEG has limitations and patients with epilepsy may present with  a normal EEG, but the EEG helps in classifying seizures. The procedure may  be carried out in a sleep-induced state or in a sleep-deprived state.   Arterial pressure reflects the stress exerted by the circulating blood on the  arterial walls. It is directly related to the cardiac output and the systemic  vascular resistance. In chronically elevated arterial blood pressure, direct  organ and vascular damage may result, caused by increased peripheral  resistance and by arteriosclerosis. Organs commonly affected include the  heart, kidneys, brain and retina. Manifestations of the sustained damage are  renovascular disease, such as renal failure; cerebrovascular disease, such as  thrombotic stroke; retinal damage resulting in visual defects; and cardio-  vascular disease, such as ischaemic heart disease.   Atherosclerosis is a common arterial disorder characterised by deposits of  plaques consisting of cholesterol, lipids and cellular debris on the inner layers  of walls of large- and medium-sized arteries. It may occur in any artery and  increases the risk of thrombosis. It is a cause of coronary artery disease,  angina and myocardial infarction. Its occurrence increases with age and is  related to smoking, obesity, hypertension, diabetes mellitus and elevated low-  density lipoprotein cholesterol levels.   Angina pectoris is thoracic pain, most often caused by myocardial anoxia.  Symptoms of angina pectoris may occur with activities or circumstances that  increase cardiac workload such as: exertion following exercise, like climbing  stairs; emotion, such as anxiety, which results in an increased heart rate; heavy  meals, because of the requirement of increased gastrointestinal perfusion; and  exposure to cold temperatures owing to peripheral vasoconstriction, which  leads to increased peripheral resistance.   A myocardial infarction occurs because of a coronary vessel occlusion for a  duration of about 6 h. Infarct size may be limited by dilatation of neighbour-  ing vessels brought about by a mechanism of autoregulation. Myocardial  infarction is caused by atherosclerosis and the patient presents with severe,  crushing, retrosternal pain. In the absence of complications, patients resume  mobilisation within 2 or 3 days of a myocardial infarction. Subsequently  patients should be advised to follow a healthy diet which is low in fats, to  undertake routine exercise and to attain a normal body weight. They should  be reassured that a gradual re-establishment of normal activity will be  achieved. Family and friends should be counselled how to help the patient  achieve this.   Gallstones consist of cholesterol and bile pigments that are calcified. Common  complications of gallstones include biliary colic, cholestatic jaundice, acute  pancreatitis and acute cholecystitis and cholangitis. In biliary colic the patient  complains of moderate to severe pain in the epigastric area. Jaundice occurs  because of obstruction of the bile ducts and presents with generalised pruritus.  In acute pancreatitis there is reflux of the bile up the pancreatic duct and it  causes pain and vomiting. Acute cholecystitis and cholangitis are due to  inflammation of the gall bladder and common bile duct.   In osteoarthritis degenerative changes including subchondral bony sclerosis,  loss of articular cartilage and proliferation of bone spurs occur in one or many  joints. As the disease progresses inflammation of the synovial membrane takes  place. The disease is not reversible except where joint replacement is under-  taken. However, disease progression is very gradual and patients should be  advised how to rest and support involved joints through proper physiotherapist-  guided exercises. Losing weight helps to reduce stress on the joints.   A major disadvantage of cytotoxic chemotherapy is that it interferes with  cellular activity in cancerous and normal tissues. It is associated with unwanted  effects because of its effect on normal cells. Nausea and vomiting after  treatment are very common side-effects. Their extent depends on the emeto-  genic potential of the drugs used. When these side-effects are not very well  controlled, there is a risk that the patient develops anticipatory nausea and  vomiting before treatment. However, this effect is psychologically and not  chemically induced. Alopecia, which is usually reversible, is another common  side-effect. Because of the suppressive effects on the bone-marrow caused by  cytotoxic chemotherapy, patients are prone to develop infections. Patients  should be advised to report any signs of an infection, such as sore throat or  fever, to a health professional.   When there is temporary loss of consciousness leading to a fall, it may indicate  a brief cerebral hypoxia, which could be caused by a number of factors  including emotional stress, vascular pooling in the legs, diaphoresis or a  sudden change in body position. Such an incident may also indicate serious  disease states, such as brain tumours. The patient should be assessed and  medical and drug histories should be reviewed.   Hypokalaemia is a decreased serum potassium level. Normally the potassium  loss from the body through renal and faecal excretion and from loss in sweat  is miminal. Hypokalaemia may result because of a high loss from the gastro-  intestinal tract, as gastrointestinal secretions contain high levels of potassium.  Vomiting, diarrhoea and laxative abuse could result in hypokalaemia. An  increased renal clearance due to drugs, alkalosis and aldosteronism may also  result in hypokalaemia. Drugs that could induce hypokalaemia include  thiazide and loop diuretics and steroids. Hyperkalaemia is the excess of  potassium in serum. It is commonly caused by renal failure.   Hypoglycaemia is a blood glucose level below 3 mmol/l. It is a condition that  develops rapidly and usually occurs in diabetics either because of an excessive  antidiabetic dose or owing to changes in lifestyle. Patients should be educated  to identify symptoms of hypoglycaemia so that they can counteract it by taking  carbohydrates, to prevent neuroglycopenic symptoms such as drowsiness,  disorientation and confusion progressing to convulsions, coma and death.  Symptoms of hypoglycaemia indicating an activated sympathetic nervous  system are sweating, tremor, pallor and anxiety. Other effects are hunger,  blurred vision, salivation and weakness.   An anaphylactic shock occurs because of a hypersensitivity reaction. Presen-  tation includes development of a rash, acute bronchoconstriction, profound  hypotension and collapse.   Diabetes is associated with microvascular complications, the incidence of  which may be reduced with optimal blood glucose control. It may lead to    microvascular damage in the retina causing dilatation, haemorrhage and  infarction leading to retinopathy. Retinopathy is managed with laser photo-  coagulation. Its occurrence is usually associated with diabetic nephropathy.  Nephropathy occurs because of sclerosis of the glomerular basement  membrane. Initial signs of nephropathy are microalbuminuria, proteinuria and  hypertension. ACE inhibitors are used in diabetic patients to treat hypertension  as well as to dilate intrarenal vessels and thus minimise glomerular hyper-  tension. Macroangiopathy occurs in cardiac vessels leading to onset of  ischaemic heart disease. To decrease the effects of macroangiopathy, lipid-  lowering drugs such as statins are considered in diabetic patients.   Normal saline consists of 0.9% sodium chloride as an isotonic solution. It is  used as a parenteral preparation in electrolyte and fluid imbalance such as  sodium depletion. It is also available as nasal drops in nasal congestion and  as a nebuliser diluent. It may be used in eye and wound irrigation and for  oral hygiene.   Topical administration of corticosteroids in the eye is associated with thinning  of the cornea and sclera, steroid glaucoma and steroid cataract. These side-  effects occur particularly after prolonged use. The use of a topical preparation  containing only a corticosteroid in a patient presenting with a red eye may  lead to aggravation of the underlying infection resulting in corneal ulceration  with a possible loss of vision.   Asthmatic patients who present with fever, chesty cough and wheezing  indicate onset of a chest infection where the use of antibacterials may  be necessary to counteract bacterial infections or to cover against the    development of secondary bacterial infections. Referral of the patients is  recommended. Patients on antihypertensive agents complaining of nasal  congestion may be recommended a topical sympathomimetic drug such as  xylometazoline, which will act as a vasoconstrictor and reduce the congestion  with minimal systemic effects. Patients presenting with allergic rhinitis could  be recommended use of systemic non-sedating antihistamine drugs such as  loratidine.    AB is an elderly male patient with congestive heart failure, hypertension and  diabetes. On admission he is taking bumetanide (a loop diuretic), potassium  chloride, isosorbide dinitrate (a nitrate), atenolol (a beta-adrenoceptor drug),  aspirin (an antiplatelet), lorazepam (an anti-anxiety drug) and metoclopramide  (an anti-emetic). Potassium chloride, isosorbide dinitrate and bumetanide may  cause nausea, though it is not a common side-effect. This may be the rationale  behind the use of metoclopramide at night. On admission he presents with  symptoms of deterioration of congestive heart failure, a high blood pressure  and an elevated fasting blood glucose level.   AB has diabetes mellitus and congestive heart failure. In elderly and diabetic  patients it is very common to find multiple disease states. Metabolic stress such  as deterioration of congestive heart failure may precipitate an acute distur-  bance in diabetic control. In AB even though there is an elevated fasting blood  glucose level, this should be monitored but no therapeutic action should be  taken until his cardiac condition is stabilised.    In congestive heart failure there is generalised oedema and usually the term  implies bilateral failure resulting in reduced cardiac contractility. Symptoms   Bumetanide is a loop diuretic, which acts by inhibiting re-absorption from the  ascending limb of the loop of Henle in the renal tubule. It has an onset of  action within 1 h of oral administration and a duration of action of about 6 h.  With regular use the impact on frequency of diuresis after drug administration  tends to decrease. One of the side-effects of bumetanide is the development  of hypokalaemia. Potassium supplements are administered to counteract this  unwanted effect. Loop diuretics are used in the management of heart failure  as they provide a symptomatic relief from the oedema. They reduce circulat-  ing blood volume and therefore decrease preload and afterload in the heart.  They do not have an impact on disease progression. Had oedema been severe  in AB on admission, changing bumetanide to an intravenous administration  for a few days until oedema is decreased could have been an option.   Isosorbide dinitrate is a nitrate that is used in the prophylaxis and treatment  of angina and in left ventricular failure. In AB isosorbide dinitrate is being  used for the management of heart failure. Nitrates cause vasodilatation and  lead to a decrease in preload. Isosorbide dinitrate is metabolised to active  metabolites, the most important of which is isosorbide mononitrate. It is  available as short-acting tablets which may also be used sublingually in  angina, as an aerosol spray, as modified-release oral dosage forms and as  injection for intravenous infusion. The dose for isosorbide dinitrate in heart  failure is 30-160 mg in divided doses but the dose may be increased to  240 mg daily.   Atenolol is a cardioselective beta-adrenoceptor blocker that is used in hyper-  tension and in angina. The recommended daily dose for atenolol in hyper-  tension is 25-100 mg, although the 50 mg dose is usually adequate. As a  beta-blocker it may mask symptoms of hypoglycaemia. However, this is of no  concern in AB as the patient is not taking any antidiabetic agents but is control-  ling diabetes through diet. Beta-blockers have negative inotropic properties  and therefore may cause bradycardia and they should not be used in patients  with uncontrolled heart failure. Treatment with beta-blockers such as atenolol  should be started with care in patients with heart failure. It has been demon-  strated that three beta-blockers namely bisoprolol, carvedilol, and metoprolol  reduce heart failure disease progression, decrease symptoms and mortality  when used in stable heart failure. In AB it is an option to consider changing  atenolol to an alternative therapeutic approach which better tackles the  concomitant occurrence of hypertension and congestive heart failure. Use of  one of these three beta-blockers (bisoprolol, carvedilol, and metoprolol) is an  option.   Lorazepam is a short-acting benzodiazepine that has anti-anxiety and hypnotic  properties. Use of benzodiazepines in older people is associated with alter-  ations in the pharmacokinetic parameters of the drug that lead to clinical  consequences such as drowsiness, confusion and ataxia (a condition charac-  terised by an inability to coordinate movement). The probability of occurrence  of these side-effects is higher with drugs that have a long halflife. The use of  lorazepam in AB raises concern as it appears that there is no clear rationale  for its use. More data is required as to reasons for its use and duration of  therapy. It may have been started recently when the patient was becoming  agitated because of the insidious deterioration of his wellbeing. Owing to the  onset of benzodiazepine dependence, lorazepam should not be stopped  abruptly if the patient has been taking the drug for a few weeks. Abrupt with-  drawal is associated with the benzodiazepine withdrawal syndrome charac-  terised by anxiety, depression, impaired concentration, insomnia, headache  and loss of appetite.   Enalapril is an angiotensin-converting enzyme (ACE) inhibitor, which causes  a decreased arterial and venous vasoconstriction and a decreased blood  volume. ACE inhibitors are considered as first-line therapy in the management  of heart failure because it has been shown that they reduce symptoms and  improve prognosis. They are also used in hypertension as they reduce salt and  water retention. The addition of enalapril to AB's therapy was an important  therapeutic intervention undertaken during hospitalisation. Before admission  the patient had a deterioration in the heart failure condition and required  further therapeutic intervention to correct progression of the disease. By  choosing to include enalapril in AB's therapy, the first-line management of  congestive heart failure is now being followed.   ACE inhibitors may cause a rapid fall in blood pressure. This may be quite  relevant to AB as the patient is already being administered other drugs that  have a hypotensive effect. For this reason, the first dose of ACE inhibitors  should preferably be started at night so that the risk of injury caused by  hypotension is lower because the patient is lying in bed. ACE inhibitors may  cause hyperkalaemia and in fact the potassium chloride supplement has been  stopped. ACE inhibitors may cause a deterioration in renal function, especi-  ally in patients with pre-existing disease, hypovolaemia and heart failure.  When initiating treatment in AB, blood pressure, serum potassium levels and  renal function should be monitored.   Upon discharge, the changes carried out in his medications should be  discussed with AB. It should be particularly pointed out that atenolol and  potassium chloride have been stopped and instead enalapril has to be taken  daily at night. AB should be advised to use the metoclopramide only when he  has symptoms of nausea.   Regarding bumetanide, AB should be advised to take one tablet daily in the  morning to avoid waking up at night because of the increased diuresis that it  causes. Bumetanide is almost completely and quite rapidly absorbed from the  gastrointestinal tract and there is no need to advise patients to take the drug  on an empty stomach.   Tolerance is associated with nitrates. By reducing the nitrate concentration  levels during the night, occurrence of tolerance is reduced and effectiveness  maintained. Patient should receive the three doses between 7 am and 6 pm.   Monitoring the outcome of therapy in AB is based on the measurement of  blood pressure, the assessment of development of oedema and dyspnoea, and  the measurement of blood glucose levels and HbAl c. A lipid profile and renal  function tests could be carried out from time to time as well.    XY presents with cellulitis, which is an acute infection of the skin and sub-  cutaneous tissue. It is characterised by erythema, oedema, swelling and pain  and may be sometimes associated with fever, malaise and headache. Occur-  rence of the condition is higher where there is damaged skin, compromised  circulation and in diabetics. The infection is commonly caused by Gram-  positive cocci. Penicillins are the preferred antibacterial agents as first-line  treatment.   In penicillin-allergic patients, macrolides are usually the preferred drugs.  Alternatively, a cephalosporin such as cefuroxime may be used with care.  Some patients who are sensitive to penicillins may be also cephalosporin  hypersensitive. Cephalosporins have a similar spectrum of activity to penicillins  and macrolides and are usually effective against Gram-positive cocci. Cefur-  oxime is a second generation cephalosporin that is less susceptible to inacti-  vation by beta-lactamases compared with first-generation cephalosporins.  Flucloxacillin is a penicillinase-resistant penicillin. Nalidixic acid is a quinolone  with activity predominantly against Gram-negative bacteria. Fluconazole is  a triazole antifungal agent and isoniazid is an antituberculous drug. In  cellulitis, when therapy is unsuccessful or inadvisable because of drug sensi-  tivity, vancomycin may be considered.   Hypersensitivity reactions may occur with any antibacterial agent. They are  more commonly recognised with penicillins. Hypersensitivity reactions vary in  presentation and may include development of a rash, an urticarial rash, fever  or an acute anaphylactic reaction. Onset of allergic reaction may occur up to  14 days from first dose administration.    PS is taking diazepam, which is a benzodiazepine, and amitriptyline, which  is a tricylic antidepressant. Tricyclic antidepressants may cause movement  disorders and dyskinesias. There are few reports where patients using benzo-  diazepines developed extrapyramidal symptoms. Elderly patients may be  particularly sensitive to the side-effects of benzodiazepines and tricyclic anti-  depressants; low doses should be used. PS is receiving the maximum dose  recommended for elderly patients for amitriptyline and the lowest recom-  mended dose for the use of diazepam in insomnia.   PS has developed tardive dyskinesia, which is characterised by involuntary  repetitive movements of muscles in the face, limbs and trunk. They may occur  as a drug-induced side-effect after prolonged therapy and elderly patients are  more prone to their occurrence. Withdrawal of the causative agent may result  in an improvement in the condition after some time.   Venlafaxine and reboxetine are antidepressant drugs that are less likely to be  associated with the development of movement disorders. Venlafaxine is a  serotonin and noradrenaline re-uptake inhibitor, whereas reboxetine is a  selective inhibitor of noradrenaline. Both drugs should be used with care in  patients with a history of cardiovascular disease, epilepsy, urinary retention,  prostatic hypertrophy, glaucoma, renal and hepatic impairment.    QR is an elderly patient who is taking a compound preparation of codeine  and paracetamol (co-codamol), paracetamol, gliclazide (sulphonylurea),  ferrous sulphate, dipyridamole (antiplatelet) and isosorbide dinitrate (nitrate).  A medication review is required.   Co-codamol is a compound preparation containing paracetamol, a non-opioid  analgesic, and codeine, an opioid analgesic. At the same time that he is taking  this product, QR is also taking paracetamol tablets. There is overlap of therapy  which could result in overdosage with paracetamol and use of codeine may  lead to constipation. Pharmacist should advise QR to stop the co-codamol and  continue taking only two paracetamol tablets every four hours. When normal-  release ferrous sulphate tablets are used, the dose of 200 mg three times daily    is recommended. For modified-release preparations, one or two tablets daily  are taken. Hence the product that is being used by QR should be verified and  the dose adjusted accordingly. QR could be advised to take the ferrous  sulphate tablets after meals so as to decrease the occurrence of gastrointestinal  irritation. QR is receiving daily 60 mg of isosorbide dinitrate, which is within  the recommended dosage for isosorbide dinitrate (up to a maximum dose of  240 mg).   The maximum adult dose of paracetamol is 4 g, administered as 0.5-1 g  every 4-6 h. Overdosage with paracetamol leads to hepatic damage, which  may have a delayed presentation of up to 6 days. The resulting hepatic  damage may lead to encephalopathy, haemorrhage, hypoglycaemia,  cerebral oedema and death. The hepatic damage is caused by a hydroxyl-  ated metabolite, N-acetyl-p-benzoquinoneimine, which is usually produced in  very small amounts and is detoxified by conjugation with gluthatione. In over-  dosage the amount of this metabolite exceeds the gluthatione potential for  detoxification.   Gliclazide is a sulphonylurea that is used as an oral antidiabetic agent. It  increases insulin secretion from functioning islet beta cells in the pancreas.  Gliclazide may be used in combination with metformin (biguanide) and  acarbose. Side-effects that may occur include mild gastrointestinal distur-  bances such as nausea, vomiting, diarrhoea and constipation. They increase  appetite and weight gain may occur. Hypoglycaemia may occur and this is  relatively uncommon unless associated with overdosage or skipped meals.   QR should be advised on healthy lifestyle measures to counteract complica-  tions associated with diabetes and cardiovascular disease. These include    small, frequent meals. Foods high in calories and sugar content should be  avoided. QR has a higher risk of developing atherosclerosis and he should  receive advice to follow a low-fat diet.   QR is receiving analgesics (paracetamol), an antiplatelet agent (dipyrid-  amole), and a nitrate (isosorbide dinitrate), which promote coronary vaso-  dilation. Patient should be asked to visit health professionals regularly to have  blood glucose levels, glycosylated haemoglobin, blood pressure and lipid  profile assessed.    MR is receiving treatment for glaucoma with dorzolamide and acetazolamide  (carbonic anhydrase inhibitors) and timolol (beta-blocker). She is receiving  ranitidine, an H 2 -receptor antagonist and bisacodyl which is a stimulant  laxative. MR is also receiving framycetin eye drops as an antibacterial  preparation.   Bisacodyl is a diphenylmethane stimulant laxative and it acts mainly on the  large intestine. Prolonged use of bisacodyl should be avoided as it may precip-  itate diarrhoea, hypokalaemia and atonic non-functioning colon. It may be  used for the short-term management of constipation and its advantage is that  it is very rapid in action. It should be avoided in intestinal obstruction and it  may cause abdominal discomfort such as colic and cramps.   In MR constipation may be a chronic problem. This is not unusual in elderly  patients who have a less physically active life, may be dehydrated and may    not include fibre in their diets. The problem is even more prominent if the  patient is bedridden. Lactulose, which is an osmotic laxative, is a semi-synthetic  disaccharide which is not absorbed from the gastrointestinal tract. It can be  used in the long-term management of constipation. Senna and docusate  sodium are very similar to bisacodyl. They are also stimulant laxatives.  Magnesium hydroxide is not indicated for regular use. It is absorbed system-  ically, causes significant bowel evacuation and may cause dehydration and  electrolyte imbalance. Use of liquid paraffin as a laxative is not recommended  as oral administration results in anal seepage and irritation and it may give  rise to foreign-body granulomatous reactions.   Framycetin is an aminoglycoside antibacterial agent which has a bactericidal  action against Gram-negative aerobic bacteria excluding Pseudomonas  species and against some strains of staphylococci. As it is not absorbed from  the gastrointestinal tract, it is used as a topical agent in skin, eye and ear  infections. Usually in eye infections, topical administration of antibacterial  drugs results in a positive outcome. Topical antibacterials, including  framycetin, may be used for prophylaxis following ophthalmic surgical inter-  ventions. The antibacterials are used for acute management or for short-term  use in prophylaxis.   MR is receiving treatment for glaucoma, which is a raised intraocular pressure  caused by obstruction of the outflow of aqueous humour. It is presented with  loss of visual field. Drug therapy is aimed at decreasing intraocular pressure.  Timolol, a beta-blocker, reduces intraocular pressure by reducing the rate of  production of aqueous humour. Dorzolamide and acetazolamide are carbonic  anhydrase inhibitors, which again interfere with the production of aqueous  humour by inhibiting the enzyme involved in the process. Dorzolamide and  timolol are applied topically, whereas acetazolamide is administered system-  ically. In glaucoma, drug therapy usually starts with monotherapy, usually    either a beta-blocker or a prostaglandin analogue such as latanoprost. As the  condition is monitored, combination therapy is resorted to until an optimum  intraocular pressure and symptom reduction occur.    The term chest infection is usually used to refer to a lower respiratory tract  infection. CB is receiving lactulose as a laxative, warfarin as an oral anti-  coagulant and paracetamol as an analgesic when required. CB has ear  problems with tinnitus and hearing loss.   Ciprofloxacin is a quinolone that is active against Gram-positive and Gram-  negative bacteria. It is an appropriate preparation for CB. A macrolide  product such as clarithromycin is also a suitable option. As CB has a history  of penicillin sensitivity, co-amoxiclav and cefuroxime should be avoided.  Cefuroxime is a cephalosporin and cross-sensitivity with penicillins is possible.  Gentamicin is an aminoglycoside that is not absorbed from the gastrointestinal  tract and requires parenteral administration. Its use in CB is not recommended  when there are other options because it may cause otoxocity as a side-effect,  resulting in a deterioration in CB's ear disorders. Sodium fusidate is a narrow-  spectrum product that is indicated in penicillin-resistant staphylococci infections  such as osteomyelitis and in staphylococcal endocarditis.   Lactulose is a semi-synthetic disaccharide that produces osmotic diarrhoea. It  can be used for the management of chronic constipation. Its use in the acute  attack is limited by the delayed onset of action (around 48 h). Side-effects of  lactulose include flatulence, cramps and abdominal discomfort.    In the terminal stages of carcinoma, pain may occur because of disease  progression, the debility it causes and owing to co-existing conditions. The  pathophysiology of pain in terminal carcinoma may be multiple because of  the varied factors leading to its occurrence. In breast cancer, bone metastases  are quite common. A multidisciplinary approach should be adopted in pallia-  tive care. The pharmacist could monitor the use of drugs to maintain the patient  as pain free as possible and to manage other problems such as the nausea  that may arise.   Co-codamol consists of a mixture of paracetamol, a non-opioid and codeine,  an opioid drug. Codeine is effective for the relief of mild to moderate pain.  An opioid drug such as morphine is required for JM. Tramadol is an opioid  analgesic that is associated with fewer side-effects compared with other  opioid drugs. However its use may increase risk of CNS toxicity when used  together with SSRIs. Aspirin and ibuprofen are non-opioid drugs that have an  anti-inflammatory and an analgesic effect. They may be of value in patients  with bone pain and may be used in addition to an opioid analgesic. Domperi-  done is used as an anti-emetic drug. It may be required with the use of opioid  drugs.   Opioid drugs used in palliative care include tramadol and morphine. Opioids  may cause nausea and vomiting especially during the initial doses, constipa-  tion and drowsiness.   Tamoxifen is an oestrogen-receptor antagonist available as an oral formulation  that is administered daily. It is used in adjuvant treatment of early breast    cancer, in the palliative treatment of advanced disease and for prophylaxis in  women at increased risk. The most frequent side-effect of tamoxifen is hot  flushes.   Paroxetine is a selective serotonin re-uptake inhibitor (SSRI) that is used in JM  to alleviate depression and anxiety associated with terminal carcinoma.  Paroxetine should be administered in the morning to minimise insomnia,  anxiety and nervousness during the night. Common side-effects of SSRIs are  nausea, vomiting, dyspepsia, abdominal pain, diarrhoea or constipation.  Occurrence of these side-effects is reduced by administering the drug with or  after food.   Diazepam is a benzodiazepine that is associated with tolerance and depen-  dence. The occurrence of dependence results in withdrawal symptoms, should  the drug be discontinued abruptly. However, these disadvantages are not of  concern in the management of JM. The aim is to keep JM pain free and in a  relatively good mental state. The advantage of using diazepam as an anxio-  lytic outweighs the disadvantages of tolerance and dependence. A disadvan-  tage of diazepam which is of concern in JM is the occurrence of confusion.    LX is taking dipyridamole (antiplatelet), aspirin (antiplatelet) and glibenclamide  (antidiabetic agent). A complication of diabetes mellitus is vascular disease in  the peripheries, which predisposes patients to the development of an infection  following trauma to the area. This occurs very commonly in the feet, a  condition referred to as the diabetic foot. For this reason diabetics are advised  to take good care of their feet, avoid injuries and foot maceration from  footwear. Diabetics should immediately seek advice about injuries to the feet  to avoid development of infections in the area.   Currently, blood glucose level is not controlled in LX. At the moment LX has an  infection that is causing metabolic stress and precipitating an acute distur-  bance in blood glucose control. Antidiabetic treatment is changed to insulin  for better control in such circumstances. Blood glucose is measured regularly  for LX and insulin dose adjusted accordingly.   Metronidazole is an anti-infective that is active against anaerobic bacteria and  protozoa. It is included in the therapeutic regimen, together with cefuroxime,  to expand the spectrum of activity of the anti-infectives used. Infection caused  by anaerobic bacteria occurs in diabetic feet infections.    Morphine is an opioid analgesic that is widely used in the management of  moderate to severe pain. It is the standard drug against which other opioid  analgesics are compared. It is particularly useful in postoperative analgesia  and palliative care. In addition to an analgesic effect it also induces a sense  of euphoria and mental detachment. Its use may result in nausea, vomiting  and constipation. Morphine may be administered as standard tablets,  modified-release tablets, oral solution and injections.   For the morning dose, FS should be given 50 mg, which can be administered  as one 30 mg tablet and two 1 0 mg tablets. This gives the least number of  tablets that the patient needs to take.   For the evening dose, FS should be given 100 mg, which can be adminis-  tered as one 60 mg tablet, one 1 0 mg tablet and one 30 mg tablet. This gives  the least number of tablets required to be taken by the patient to achieve the  required dose.    CP is receiving gliclazide (sulphonylurea), esomeprazole (proton pump  inhibitor) and an antacid preparation. From this medication profile it is under-  stood that CP is a diabetic. He has a history of duodenal ulcer disease. In the  majority of cases this is caused by the organism Helicobacter pylori and a  triple-therapy eradication regimen is recommended in these cases. However,  in some patients there may be other factors that lead to duodenal ulceration.  These include use of non-steroidal anti-inflammatory drugs (NSAIDs) and  family history, especially when it occurs at an early age such as in the case  of CP.   In CP a cause of anaemia is gastrointestinal haemorrhage, a complication of  gastric or duodenal ulcer disease, which may occur either as a minor chronic  blood loss leading eventually to anaemia or as moderate bleeding leading to  melaena or haematemesis. The bleeding results because of erosion of an ulcer  into an artery.   A priority in the management of CP is to correct the anaemia by administer-  ing iron supplements. Iron salts should be administered by the oral route, unless  this has been unsuccessful because of non-compliance, intolerance to side-  effects, malabsorption and continued blood loss. CP should be started on    ferrous sulphate tablets and haemoglobin levels monitored. Iron is absorbed  mostly as the ferrous state in an acidic environment and hence absorption  takes place mostly in the stomach. Modified-release preparations are not  recommended for CP as they do not undergo sufficient dissolution until  reaching the small intestines where absorption of iron is poor. Absorption may  be reduced by food; however, many patients experience nausea and  diarrhoea when iron is administered on an empty stomach.   CP should be advised to avoid non-steroidal anti-inflammatory drugs such as  aspirin and to inform prescribers and pharmacists of his condition before using  other medications. NSAIDs are very likely to cause gastrointestinal distress and  precipitate an acute attack. He should be advised to take regular small meals,  avoid strong tea, coffee and spicy food and limit food intake late at night as  this increases nocturnal gastric secretion. Anxiety, stress, alcohol and smoking  all contribute to precipitate duodenal ulcer disease.    MC is receiving treatment for diabetes mellitus, congestive heart failure and  ischaemic heart disease. She also has a history of dementia. She is taking  perindopril (angiotensin-converting enzyme inhibitor), digoxin (cardiac  glycoside), bumetanide (loop diuretic), metformin (biguanide), amitriptyline  (tricyclic antidepressant) and ranitidine (^-receptor antagonist). MC is  presenting poor respiratory effort, sparse bilateral inspiratory crackles and  poor general health, indicating the possibility of an underlying infection. The  white blood cell count indicates that there is no leucocytosis. However, in  elderly patients, bacterial infections may not necessarily induce leucocytosis.   Onset of dehydration may be precipitated by decreased fluid intake and by  loop diuretics. Risk of dehydration increases with environmental factors that    support fluid and electrolyte loss, such as heat exposure caused by hot temper-  atures and inadequate ventilation at home. Amitriptyline may cause dry mouth  and sweating but these effects are not related to sufficient fluid loss to cause  dehydration.   In elderly patients a normal white blood cell count is not sufficient to eliminate  the presence of an infection and MC has clinical signs that may indicate an  infection. MC should be started on co-amoxiclav therapy intravenously. When  her general condition and the respiratory features improve, treatment may be  continued orally. The use of corticosteroids without the use of anti-infective  agents will present a general improvement in MC but will leave the infection  untreated. This is very dangerous and should be avoided.   When MC is started on parenteral rehydration with intravenous 0.9% sodium  chloride 1 litre alternating with 5 % dextrose 1 litre every 8 h, blood sodium  levels and blood glucose should be monitored. The bumetanide should be  stopped until dehydration status is corrected, and then it should be re-  introduced carefully. MC was started on sodium chloride and dextrose as she  has combined electrolyte and fluid deficiency. Dextrose used alone is intended  when there is fluid loss without significant loss of electrolytes. This is very  uncommon.   Metformin is an antidiabetic drug that has the advantages that it does not  increase appetite and that occurrence of hypoglycaemia is very low. Its disad-  vantage is that it may provoke lactic acidosis, especially in patients with renal  impairment. In MC renal function should be monitored, and signs and  symptoms of lactic acidosis should be noted as dehydration poses a higher  risk of lactic acidosis. Side-effects of metformin include anorexia, nausea,    vomiting, abdominal pain. To reduce gastrointestinal symptoms, the patient  should be advised to take the drug with meals. Diarrhoea may occur initially  and is only transient. When alcohol is consumed with metformin, the risk of  lactic acidosis is increased. MC should be advised to avoid alcohol as it may  interfere with her medications, it may precipitate dehydration and cause a  deterioration in her general condition because of her dementia.   Amitriptyline and imipramine are tricyclic antidepressants that have a tertiary  amine structure. Imipramine is a dibenzazepine with a structure that is very  similar to the phenothiazines, whereas amitriptyline is a dibenzocyclohepta-  diene that has a structure which resembles thioxanthenes. Amitriptyline is more  sedative than imipramine. Tolerance to this effect tends to develop with long-  term treatment. Elderly patients may be particularly sensitive to the side-effects  of tricyclic antidepressants and reduced doses are recommended. MC is  taking a dose of 20 mg at night, probably to induce sleep and reduce anxiety.  The dose is appropriate for the age group. Use of amitriptyline in MC requires  review as its use may result in cardiotoxicity and it may alter blood-glucose  concentrations, which may include hypoglycaemia unawareness. It may also  cause confusion, which is a problem in MC as she also has dementia.   MC has presented with early parkinsonian features. Bradykinesia which is  general slowness of movement, is the main symptom for parkinsonism, which,  during the initial phases of the disease, may occur as the only symptom or in  combination with tremor at rest that disappears with activity and muscular  rigidity. Postural instability is a late feature of the condition and increases the  tendency to fall. As the disease progresses, patients develop reduced blink  frequency, monotonous and impaired speech, greasy skin leading to sebor-  rhoea, urinary incontinence and constipation.   Amitriptyline, being a tricyclic antidepressant, may cause movement disorders  and dyskinesias. Parkinsonian symptoms in MC may be precipitated by the  administration of amitriptyline. The involvement of a physiotherapist in MC's  healthcare team could help her to follow exercises that would delay onset of  muscle rigidity and allow her to carry out normal daily activities at home with  minimal support.    Eczema is a chronic inflammatory skin condition. Atopic eczema occurs mostly  in children and it is characterised by pruritus, itchy papules, inflamed and  lichenified skin especially on flexures such as elbows and knees. It is associ-  ated with a family history of asthma and hayfever and it may be exacerbated  by allergens. The area may become infected because of pruritus, leading to  a flare-up of the condition and a bacterial infection. Common causative  bacteria include staphylococci and streptococci.   BC may have an exacerbation of atopic eczema or impetigo, which is a  common occurrence in patients with atopic eczema, as the area becomes  infected because of the scratching that is associated with intense itching.  Atopic eczema is a chronic condition that may be exacerbated by exposure  to allergens such as clothing fibres, by changes in environment such as  exposure to sun, hot temperatures or cold temperatures. Impetigo is a skin  infection characterised by pruritic vesicles and golden-coloured crusts. It is  caused by Gram-positive cocci and is a contagious condition. Ringworm  infection is a fungal infection and when it occurs on non-hairy areas (tinea  corporis) it is characterised by discoid, erythematous scaly plaques.   In the management of an acute attack of atopic eczema, topical corticosteroids  should be recommended. The use of 1% hydrocortisone cream is a suitable  choice for BC considering that she is a child and it is a mild steroid which is  rarely associated with side-effects. In addition as there is a very high proba-  bility that BC also has impetigo, a topical anti-infective agent such as fusidic  acid, which is effective against Gram-positive cocci, could be administered.  Topical antihistamines such as mepyramine should be avoided in eczema as  they may cause hypersensitivity reactions and exacerbate the condition.  Miconazole cream is an antifungal cream which is indicated for use in fungal  skin infections.   Parents of BC should be educated on the importance of preventing dehydra-  tion of the skin by ensuring good hydration and by using emollients. They  should be advised on the regular use of emollients, to avoid soaps and bubble  baths and to use emollient bath oils instead. They should be informed that the  condition may be exacerbated by allergens such as wool, excipients in  cosmetic cream preparations, and by sun exposure. They should be advised  to use a hypoallergenic sun protection cream.    GM states that she suffers from tension headache, a condition that is also  referred to as muscle contraction headache. It occurs as a result of a stressful  situation, such as activities that cause the individual stress and anxiety (psycho-  logical and environmental factors). The attack may last from several hours to  a number of days. Management of the condition includes analgesics, helping  the patient to identify activities that precipitate an attack, physical therapy such  as heat application to the head and neck area, and relaxation techniques.   Tension headaches tend to occur repeatedly in patients who are prone to  develop this syndrome. Females experience this condition to a greater extent  than males. It may occur at any age and arises because of prolonged contrac-  tion of the head and neck muscles. Arterial vasoconstriction in the brain is  associated with the prodromal effects of migraine. The vasoconstriction is  followed with vasodilation and inflammation leading to pain associated with  a migraine attack.   Patients with tension headache complain of mild, dull ache that is steady and  usually bilateral and non-throbbing. There is scalp tenderness and tightness.  They may have sound intolerance and pain may radiate to occipital and  frontal areas and neck.   GM should be advised to identify factors that are precipitating her attacks.  These could include prolonged posture posing strain on head and neck  muscles and activities that induce stress. She could be advised to take up some  physical activity that will help her to relax. Specific food consumption has not  been established to have a direct effect on the occurrence of tension  headache. It has been documented that dietary factors such as consumption  of cheese and wine may induce migraine attacks.   Drugs that can be used to manage an acute attack include paracetamol, non-  steroidal analgesics (NSAIDs) such as ibuprofen and combination products  such as co-codamol, which contains paracetamol and codeine. NSAIDs  and products consisting of paracetamol with an opioid drug such as the    co-codamol combination present a better analgesic profile. NSAIDs are anti-  inflammatory and this may help in patients where neck muscle inflammation  is prominent.   Aspirin should not be recommended to GM if she has a history of gastric  irritation or if she is breast-feeding. Irritation of the gastric mucosa leading to  erosion and ulceration may occur with administration of aspirin and other  NSAIDs; the risk is higher in patients with a history of dyspepsia or a lesion  of the gastric mucosa. When used during breast-feeding, aspirin enters breast  milk and it is transferred to the infant. Aspirin should be avoided during breast-  feeding because there is a risk of Reye's syndrome in the infant. Reye's  syndrome is a condition characterised by acute encephalopathy and fatty  degeneration of the liver that is associated with the use of aspirin in children.  Regular use of aspirin by breast-feeding mothers may impair platelet function  in the infant resulting in hypoprothrombinaemia. Aspirin or other NSAIDs  should not be recommended if GM had haemophilia, as it increases the risk  of bleeding, and if GM had asthma, as hypersensitivity and paroxysmal  bronchospasms may be precipitated.   headings followed by a list of numbered questions. For each  numbered question select the one heading that is most closely  related to it. Each heading may be used once, more than once,  or not at all.   Select, from A to I, which one of the above is associated with:   Q2 accumulation of fat on the face, chest and upper back   may occur as a result of hyperparathyroidism  Q5 may present with arrhythmias    Directions: For each of the questions below, ONE or MORE of the   responses is (are) correct. Decide which of the responses is  (are) correct. Then choose:    A □ if 1 , 2 and 3 are correct  B □ if 1 and 2 only are correct    Unexpected fluctuations in dose response in patients receiving warfarin  may be attributed to:   Q1 1 When candesartan is started in the older person, recommended moni-  toring includes:   2 □ is the drug of first choice in managing delayed   Q14 Dose reduction and delays in administration of planned cytotoxic  chemotherapy are caused by:   2 Q spreading of infection may be reduced by alcohol hand rubs   1 □ is associated with cessation of breathing for at least   patient profile and answer the questions. For questions with  one or more correct answers, follow the key given with  each question. For the other questions, only one answer is  correct - give the corresponding answer.   SN is a 25-year-old female who is admitted to the emergency department.  PMH asthma   beclometasone 200 ,ug/ puff inhaler two puffs twice daily  PC chest tightness, exhaustion  O/E pulse >1 10 bpm   salbutamol nebuliser 2.5 mg four times daily  hydrocortisone intravenous 200 mg every 6 h  cefuroxime intravenous 750 mg every 8 h  clarithromycin tablets 500 mg twice daily  beclometasone inhaler two puffs twice daily   Q28 Inflammatory mediators that are released in an asthmatic attack include:   Q30 Signs and symptoms in SN of an acute severe asthma attack include:   A □ it may mask symptom severity  B □ aggressive treatment is required  C □ the dose is lower than administered by inhaler  D □ it may cause hypovolaemia  E □ it may cause arterial hypoxaemia   Q33 If SN's condition does not improve after 30 minutes, the following may  be added to the drug therapy:    After 24 h SN is reviewed and the following changes are made to the drug  therapy:   change frequency of administration of salbutamol nebuliser to three times daily   Q4 Long-term inhalation of high doses of beclometasone may predispose  patients to:    Q43 SN could be counselled on signs indicating exacerbation of the  condition. She could be advised to report:   -old obese male who presents with sudden onset of chest pain.   enalapril tablets 20 mg daily  aspirin enteric-coated tablets 75 mg daily  furosemide tablets 20 mg daily  metformin tablets 500 mg daily  ranitidine tablets 150 mg nocte   sudden onset of chest pain radiating into throat and left arm,  patient is sweating and feeling breathless    GL is discharged and in addition to his medication on admission he is started on  simvastatin tablets 20 mg at night and glyceryl trinitrate patch.   2 □ that this medication is only for short-term until LDL levels  normalise   Q56 With regards to the glyceryl trinitrate patch, GL should be advised:   1 □ to apply patch on chest wall, upper arm or shoulder   Q5‘ Additional drug therapy that could be suggested for GL for long-term  management include:   MG is a 64-year-old male who was admitted to hospital with a stroke. On  admission MG was taking nifedipine slow-release tablets 20 mg three times daily  and aspirin tablets 75 mg. He has a past history of hypertension.   MG is started on dipyridamole tablets 100 mg three times daily.   GX is an 80-year-old female who lives on her own and is receiving the following  medication:   glibenclamide tablets 10 mg am and 15 mg mid-day  isosorbide mononitrate tablets 60 mg daily  aspirin enteric-coated tablets 75 mg daily  perindopril tablets 8 mg daily  calcium tablets 600 mg daily  cod liver oil capsules once daily    Q63 For which of the following drugs is there an alternative drug that is more  appropriate for GX?   2 □ dose in GX should be reviewed due to under-dosing   PMH rheumatoid arthritis  DH methotrexate tablets 1 5 mg weekly  folic acid tablets 1 0 mg weekly  prednisolone tablets 5 mg daily  vitamin D and calcium tablets twice daily  disodium pamidronate injection 90 mg every 3 months   Q68 In monitoring effectiveness of treatment for AV, functional factors to be  assessed include:   MA is a 71 -year-old male who was diagnosed with shingles about 3 months ago.  During the active phase of the disease MA received famciclovir tablets 250 mg  three times daily for 7 days. MA is still complaining of pain in the area although  he reports that the rash has now cleared.    1 □ occurs when varicella zoster virus is reactivated from its   2 Q postherpetic neuralgia does not exceed 2 months in duration   Q80 Drugs that could be used to manage the condition of AAA include:    An understanding of pathology of disease states is essential to be able to use  drug therapy appropriately and rationally. Unwanted effects of medications  may have an impact in a particular patient because of concomitant disease  states, resulting in deterioration of the condition.   Wilson's disease is a rare disorder associated with a decrease in cerulo-  plasmin, which causes copper to accumulate slowly in the liver and then be  released into the circulation where it is taken up by other tissues. It is an  inherited disorder. Accumulation of copper in the brain causes tremors, muscle  rigidity and speech impairment, whereas its accumulation in erythrocytes leads  to haemolysis and haemolytic anaemia.   Cushing's disease is a disorder where there is an increased secretion of  adrenocortical steroids. This results in accumulation of fat on the face, chest  and upper back and leads to the development of oedema, hyperglycaemia,  increased gluconeogenesis, muscle weakness and osteoporosis. In women,  acne and facial hair growth may occur. The condition is caused by increased  amounts of adrenocorticotrophic hormone, which is released from the pituitary.   Phaeochromocytoma is a tumour of the chromaffin tissue of the adrenal  medulla or sympathetic paraganglia. Its occurrence results in hypersecretion    of adrenaline and noradrenaline leading to the development of persistent or  intermittent hypertension, headache, palpitations, sweating, hyperglycaemia,  syncope, nausea and vomiting.    Serum electrolytes are regularly performed in a battery of clinical laboratory  tests. A change in the concentration of electrolytes in blood is important  information that is required for diagnosis and for patient monitoring.   Hypercalcaemia usually occurs as a result of hyperparathyroidism or because  of carcinoma. The serum calcium measurement is used to evaluate parathyroid  function and calcium metabolism. Hyperparathyroidism leads to increased  parathyroid hormone levels, which lead to increased gastrointestinal  absorption of calcium, decreased calcium urinary excretion and increased  bone resorption. Symptoms of hypercalcaemia include nausea, vomiting,  somnolence and coma.   Hypokalaemia leads to decreased contractility of smooth, skeletal and cardiac  muscle. This predisposes the patient to weakness, paralysis and cardiac  arrhythmias.   Hypokalaemia increases cardiac muscle sensitivity to digoxin and hence  patients are more prone to digoxin toxicity. Patients who are taking digoxin  and may be predisposed to hypokalaemia should have their serum potassium  levels monitored and potassium supplementation may be required. Digoxin    toxicity is manifested by anorexia, nausea, vomiting, diarrhoea, abdominal  pain, visual disturbances, headache, confusion, drowsiness, arrhythmias and  heart block.   Fentanyl is a phenylpiperidine derivative and it is a potent opioid analgesic,  which is a pure agonist of p-opioid receptors. Self-adhesive patches releasing  fentanyl are used for chronic intractable pain. The transdermal drug delivery  system releases the drug for about 72 h. Fentanyl may be given by intra-  muscular or intravenous injection as an adjunct to anaesthesia.   Warfarin is an anticoagulant that acts by reducing the vitamin-K-dependent  synthesis of coagulation factors in the liver. Any activity that changes vitamin  K concentrations in the body may result in unexpected fluctuations in dose  response in patients receiving warfarin. An increase in vitamin K levels through  direct vitamin K intake or through an increased intake of salads and vegetables  reverses the effect of warfarin. A decrease in consumption leads to a higher  anticoagulant effect for the same dose of warfarin as the levels of vitamin K,  which oppose its activity, are reduced. Alcohol has a variable effect on  warfarin therapy and major changes in consumption may lead to changes in  therapeutic outcome.   Clozapine is a dibenzodiazepine which is used as an atypical antipsychotic.  It has activity as a dopamine-receptor blocker, an antiserotonergic, an anti-  muscarinic, an alpha-adrenergic blocker, and an antihistamine. It is indicated  in schizophrenia. A major disadvantage is that it may precipitate agranulo-  cytosis.   Ciclosporin is a calcineurin inhibitor that is used as an immunosuppressant in  organ and tissue transplantation. It has a very specific action on T-lymphocytes  and little effect on the bone marrow. It inhibits the activation of calcineurin,  which is required for the production of lymphokines, including interleukin-2.  When treatment is started, kidney function should be monitored for the first  few weeks as a dose-dependent increase in serum creatinine and urea may  occur.   Candesartan is an angiotensin-ll receptor antagonist. When candesartan is  started in older persons, monitoring of plasma potassium concentration is  recommended as hyperkalaemia may occur occasionally. Older people may  be more prone to develop this side-effect because of reduced renal function.   Prostate cancer is a slowly progressive adenocarcinoma of the prostate gland.  It is detected by prostate-specific antigen test and digital rectal examination.  The prostate-specific antigen test evaluates the amount of protein produced by  the prostate. The concentration of the protein is elevated in patients with cancer  or other prostate disease states. Prostate cancer is largely hormone-related  and is associated with androgen-dependent growth. Treatment is aimed at  androgen depletion and includes use of anti-androgens such as cyproterone  and gonadorelin analogues such as goserelin.   Ondansetron is a 5-HT 3 antagonist which acts as an anti-emetic by blocking  serotonergic receptors in the gastrointestinal tract and in the central nervous  system. It is used to counteract cytotoxic chemotherapy-induced nausea and    vomiting, and in the postoperative nausea and vomiting that can be caused  by anaesthetics and opioid analgesics. In the management of chemotherapy-  induced nausea and vomiting, ondansetron is used in patients who are  receiving highly emetogenic drugs or when other anti-emetics were inadequate  for the prevention of acute symptoms. It may be administered in combination  with dexamethasone to improve symptom control. Metoclopramide and  prochlorperazine are more effective than the 5 -HT 3 antagonists in the preven-  tion of delayed chemotherapy-induced nausea and vomiting. Ondansetron is  not effective for the prophylaxis of motion sickness. In motion sickness the  vestibular apparatus in the ear stimulates the vomiting centre in the medulla  of the brain, resulting in nausea, pallor, sweating and increased salivation.  5-HT3 antagonists have minimal effects on the vomiting centre. Hyoscine and  centrally acting antihistamines such as cinnarizine and dimenhydrinate are  used in the prevention of motion sickness.   Cytotoxic drugs cause damage to normal cells, particularly where normal cell  division is fairly rapid, including hair follicles, resulting in alopecia and bone-  marrow suppression. For cytotoxic drugs that are irritant or vesicant, local irri-  tation and inflammation at the administration site may lead to extravasation.  Ulceration and necrosis may develop and further dose administration should  be undertaken at other sites. When bone-marrow suppression occurs this may  result in leucopenia. Its occurrence is a dose-limiting factor as further drug  administration has to be delayed until the leucocyte count is normalised.  Leucopenia increases the risk of infection. Patients should be advised to report  any signs of infection, such as fever, immediately. Colony-stimulating factors  such as filgrastim, pegfilgrastim and lenograstim may be used to reduce the  duration of neutropenia in patients receiving cytotoxic chemotherapy.   In spirometry, the patient is asked to inhale and then to exhale as rapidly as  possible into a spirometer, which records the volume of air exiting the lungs.    Forced vital capacity is measured as it is the amount of air that can be moved  during maximal inhalation and exhalation. The residual volume is the volume  of air that remains in the lungs after maximal expiration and this value together  with the forced vital capacity gives the total lung capacity.   Methicillin-resistant Staphylococcus aureus (MRSA) strains are resistant to a  number of antibacterial drugs. They may be sensitive to vancomycin or  teicoplanin. MRSA infections usually occur as a hospital-acquired infection  (nosocomial infection). Patients with identified MRSA infections are isolated  and carers are asked to undertake special precautions to restrain the spread  of infections. Using alcohol hand scrubs after handling patients decreases the  spread of infection. As management of the condition requires isolation of the  cases and use of expensive medications, MRSA infections in an institution  represent an economic burden.   Alanine aminotransferase (ALT) is an enzyme that is found mainly in the liver  with lower amounts also present in the kidneys, heart and skeletal muscle. Its  quantification in blood is used to identify hepatocellular diseases of the liver.  In liver injury or conditions such as viral hepatitis, ALT levels are increased as  it is released into the bloodstream.   Aldosterone is a mineralcorticoid hormone which is produced by the adrenal  cortex with action in the renal tubule resulting in sodium and water retention  and potassium secretion in urine. Production of aldosterone is regulated  primarily by the renin-angiotensin system and to a lesser extent by adreno-  corticotrophic hormone, sodium and potassium levels. Low serum sodium levels  and high potassium levels stimulate aldosterone production.   Occurrence of protein in urine (proteinuria) is an indicator of renal disease,  as normally protein is not present in urine because it cannot pass through the  glomerular membrane in the renal tubules. When the glomerular membrane  is damaged, protein such as albumin seeps through the enlarged gaps in the  membrane. Urinalysis to identify presence of proteinuria is carried out to detect  renal disease and to detect pre-eclampsia in pregnant women. If urinalysis  indicates that there is significant proteinuria, a 24-h urine specimen is collected  to quantify the protein loss in 24 h.   Type I diabetes usually occurs in young people and is characterised by an  inability of the beta-cells in the pancreas to produce insulin. Disease manage-  ment requires insulin replacement using insulin. Patients should be encouraged  to undertake self-monitoring of blood glucose so as to avoid changes in blood  glucose levels leading to hyperglycaemia or hypoglycaemia. Patients should  be advised to lead a normal lifestyle and should be educated on how to  recognise the onset of hypoglycaemia. When symptoms of hypoglycaemia  such as sweating, tachycardia and hunger occur, the patient is advised to take  immediate action by consuming fast sugars such as glucose itself or sweets.  Sports and exercise reduces insulin requirements and decreases cardio-  vascular risk. A lower dose of insulin may be required before and after sports  activities.   Aspirin is an antiplatelet drug that decreases platelet aggregation, whereas  warfarin is an oral anticoagulant that antagonises the effects of vitamin K.  Disadvantages of aspirin when it is used for its antiplatelet effects are that it  may cause bronchospasm and haemorrhage including gastrointestinal.  Occurrence of haemorrhage is much higher with warfarin and for this reason,  patients receiving warfarin should have their prothrombin time monitored.   Gallstones consist of cholesterol or bile and are usually asymptomatic. During  an acute attack patients usually present with biliary colic that is represented  with severe, episodic visceral pain in the abdomen. Pain may be precipitated  by a large meal. In patients where the gallstones consist mainly of cholesterol,  pain is precipitated with meals that have a high-fat content. Presence of gall-  stones is confirmed by ultrasound.   Sleep apnoea is characterised during sleep by periods of cessation of  breathing ranging from 10 seconds to 3 minutes. It results in loud snoring and  gasping. It occurs commonly in obese patients and in patients with chronic  obstructive pulmonary disease. Patients with sleep apnoea may complain of  daytime sleepiness caused by their fragmented sleep at night. Weight loss in  obese patients is recommended as a non-pharmacotherapeutic management  strategy.   Cannabis is in many countries an illegal drug and may not have approval for  medicinal use. It has analgesic, muscle relaxant and appetite stimulant effects.  It reduces intraocular pressure and has anti-emetic properties. Nabilone is a  synthetic cannabinoid that is used for its anti-emetic properties in the manage-  ment of cytotoxic chemotherapy-induced nausea and vomiting that are  unresponsive to other anti-emetic modalities.   Corticosteroids have mineralcorticoid effects that result in sodium and water  retention, which leads to hypertension. Phenothiazines, which are used as  antipsychotic drugs, have antimuscarinic and alpha-adrenergic blocking    effects. They cause antimuscarinic side-effects such as dry mouth, constipation  and difficulty with micturition. They may cause hypotension especially in older  people. Alpha-adrenoceptor blocking drugs are used in hypertension and in  benign prostatic hyperplasia. They block the alpha-adrenoceptor in the sympa-  thetic nervous system causing vasodilation. Side-effects include hypotension,  dizziness, vertigo, headache, fatigue, oedema and sleep disturbances.   Iron tablets may cause gastrointestinal irritation and patient may complain of  nausea and epigastric pain. The occurrence of these side-effects is reduced  by advising the patient to take the preparation with food, even though this  strategy lowers the absorption of iron. Side-effects may lead to the patient not  taking the medication. Administration of iron salts may lead to discoloration  of stools.    SN is an asthmatic patient who is using, by inhalation, salbutamol, a short-  acting beta 2 agonist and beclometasone, a corticosteroid. Asthma is a respi-  ratory condition that is characterised by episodes of dyspnoea and wheezing  caused by bronchial constriction, coughing and viscous bronchial secretions.  Acute asthma attacks when severe may be fatal. On admission, salbutamol is  administered by nebuliser and SN is given oxygen. She is started on hydro-  cortisone intravenously as an anti-inflammatory drug, cefuroxime (second-  generation cephalosporin) intravenously and clarithromycin orally (macrolide)  as the antibacterials. Beclometasone inhaler therapy is continued.   An asthmatic attack may be precipitated by various factors such as allergens  (e.g. pollen), foods (for example, tartrazine colorant) and environmental  factors (such as cold air, dust and cigarette smoke). Exposure to these factors    may lead to bronchospasm which is followed by the development of increased  airways resistance and inflammation.   In an acute attack there is an increase of eosinophils in the bronchial epi-  thelium releasing proteins and neurotoxins which damage the epithelium. In  addition inflammatory cells such as mast cells and basophils release spasmo-  gens such as histamine, leukotrienes, prostaglandins, thromboxane and  platelet-activating factor. These result in bronchospasm and oedema, inflam-  mation and airway hyperactivitiy.   Drugs that induce bronchospasm may provoke an asthmatic attack in patients  with asthma. SN should be advised to avoid using non-steroidal anti-inflam-  matory drugs (NSAIDs) such as diclofenac as they may provoke an asthma  attack. NSAIDs inhibit cyclo-oxygenase resulting in an increased amount of  arachidonic acid that is available. A higher arachidonic acid concentration  leads to an increased leukotriene production. Beta-adrenoceptor blockers such  as atenolol and timolol may also precipitate an asthmatic attack as they block  the sympathetic nervous system and hence induce bronchospasm in the  bronchial smooth muscle.   On examination SN had rapid heart rate (tachycardia). During an acute attack  patients suffer from dyspnoea and with increasing severity of the attack they  become anxious, which also increases their heart rate. SN also presented  tachypnoea with a respiration rate exceeding 20 breaths/minute. This is  caused by hyperventilation, which results in patients feeling unable to speak  and complete sentences. SN also presented with exhaustion. Severe asthma  attacks interfere with patients' sleep because of the distress caused, particu-  larly when the patient is lying down in bed.   The aims of treatment for SN are to promote recovery and to prevent further  deterioration. Up to 60% oxygen may be used and in fact SN was adminis-  tered 60% oxygen. In an acute, severe asthma attack, the arterial carbon  dioxide is usually decreased. During the severe attack, use of nebuliser  solutions of salbutamol may only aggravate hypoxia. SN is receiving oxygen  in conjunction with nebulised salbutamol as salbutamol may increase arterial  hypoxaemia.   As soon as SN is hospitalised, peak expiratory flow rate, blood gases and  serum electrolytes should be measured. These parameters should be continu-  ously monitored to assess improvement in the condition. Blood gases are  required to assess hypoxia (P a 0 2 <8 kPa) and to evaluate arterial carbon  dioxide. During hypoxia, the risk of hypokalaemia is increased and this risk  is increased with the administration of salbutamol, which increases cellular  potassium uptake.   SN has been administered hydrocortisone by intravenous injection which,  together with the oxygen and the nebulised salbutamol, is aimed to improve  respiration and pulse within 30 minutes. If this is not achieved, ipratropium by  nebulisation may be considered. Ipratropium is an antimuscarinic broncho-  dilator that when administered by nebulisation is very specific for lung tissue  and presents minimal side-effects. Use of nebulised solutions of ipratropium  are associated with the occurrence of acute angle closure glaucoma caused  by ipratropium aerosol coming in contact with the eye. The risk is further  increased if it is administered with nebulised salbutamol. Nebulised ipratro-  pium should be avoided in patients with glaucoma and care should be taken  to avoid escape of ipratropium aerosol. This can be minimised by using a  tightly fitting mask. Intravenous aminophylline is another option as SN has not  been administered theophylline. Aminophylline has a different mode of action    to salbutamol and ipratropium. As aminophylline is associated with more  adverse effects including a higher risk of hypokalaemia, its use should be  restricted to attacks where improvement is not achieved with the other lines of  treatment. Aminophylline is administered as a slow intravenous bolus dose  because it causes venous irritation and rapid bolus doses may precipitate  cardiac arrhythmias, profound hypotension and hypokalaemia.   Cefuroxime is a second-generation cephalosporin that is active against Gram-  positive cocci and against beta-lactamase-producing strains of Haemophilus  influenzae and Neisseria gonorrhoeae. The acetoxyethyl ester of cefuroxime  (cefuroxime axetil) is available for oral administration and the dosage regimen  in respiratory tract infections is usually 250-500 mg twice daily.   Clarithromycin is a macrolide that is derived from erythromycin. Compared  with erythromycin, clarithromycin is better absorbed from the gastrointestinal  tract, it achieves higher tissue concentrations and has enhanced activity  against Haemophilus influenzae.   Hydrocortisone is a glucocorticoid drug. It stimulates the synthesis of lipocortin,  which inhibits the production and release of intrinsic agents that are associ-  ated with inflammation such as phospholipase A2, prostaglandins and  leukotrienes.   Prednisolone is an oral glucocortioid that is given instead of intravenous hydro-  cortisone. It has predominantly glucocorticoid activity. Systemic administration    of glucocorticoids results in suppression of cortisol secretion from the adrenal  cortex and prolonged, high-dose therapy may lead to atrophy of the adrenal  cortex. As cortisol secretion is greatest in the morning, the dose should be  administered in the morning to minimise disturbance in circadian cortisol  secretion. Prednisolone dose should be continued until SN is stabilised. Peak  expiratory flow rate should be monitored and care should be taken not to  precipitate the condition with early withdrawal of oral prednisolone.  Depending on the duration of the oral prednisolone therapy, gradual with-  drawal may be required to avoid withdrawal symptoms caused by adreno-  cortical insufficiency.   Oral prednisolone may cause dyspepsia and oesophageal and peptic ulcer-  ation. Occurrence of these side-effects is reduced by administering the drug  after food and by using an enteric-coated formulation.   Nebulisers are medical devices that are used to convert a solution to an  aerosol. They can deliver higher doses compared with a metered-dose inhaler.  They are preferred in patients who have difficulty in using a metered-dose  inhaler, and when higher doses are required such as in an acute attack. Nebu-  lisers should be washed out after each use or at least daily to avoid microbial  growth and consequent infection. Solutions that are prepared for use in nebu-  lisers should be used. Salbutamol is available as solution for nebulisation.   Beclometasone is a corticosteroid that is being administered to SN as a  metered-dose inhaler. Beclometasone and budesonide are equally effective in  the management of asthma and they are used as prophylactic therapy to  reduce airway inflammation. A common side-effect of inhaled corticosteroids  is the development of oral candidiasis. This occurs due to deposits of the drug    in the oral cavity promoting superinfection with local Candida species. SN  may be advised to rinse her mouth with water after inhalation so as to  decrease onset of oral candidiasis.   With long-term inhalation of high doses of beclometasone (greater than  800 pg daily), patients are predisposed to the occurrence of adrenal  suppression, osteoporosis, hoarseness and glaucoma.   Salmeterol is a long-acting beta 2 agonist with a duration of action of about  12 h. Onset of action occurs within 1 0 to 20 minutes of administration by  inhalation but the maximum effect is not achieved until regular administration  of successive doses. It cannot replace salbutamol in the relief of an acute  asthma attack. It is recommended to be used in combination with an inhaled  corticosteroid as life-threatening asthma attacks have been reported following  the use of salmeterol without an inhaled corticosteroid.   SN should be advised to monitor for signs that indicate an exacerbation of  her condition. She should be advised to report any decrease in exercise  tolerance, increased requirements for salbutamol inhaler, and any decrease  in peak expiratory flow rate immediately so that her medication may be  adjusted so as to avoid the development of an acute, severe attack.    GL suffers from a history of diabetes, hypertension and ischaemic heart  disease. He has a history of a myocardial infarction. On admission GL is    taking enalapril (angiotensin-converting enzyme inhibitor), aspirin as an  antiplatelet, furosemide (loop diuretic), metformin (biguanide) and ranitidine  (H 2 -receptor antagonist). He is admitted with an acute attack of unstable  angina. On admission GL is administered heparin (anticoagulant) and isosor-  bide dinitrate (nitrate).   Ischaemic heart disease may present with symptoms of angina or develop a  myocardial infarction. Angina is due to a mismatch in the oxygen supply and  oxygen demand of the cardiac muscle. GL is presenting the characteristic  symptom of an angina attack, the sudden onset of chest pain radiating into  throat and left arm. In addition, he presents breathlessness, tachycardia with  a pulse rate of 140 beats per minute which requires immediate correction,  and sweating.   Diagnosis is based on past medical history and on the presenting symptoms.  An electrocardiogram during an attack will confirm diagnosis by indicating  an ST-segment depression. Hypertension may occur during an acute attack of  angina and it requires correction. Blood pressure should be monitored.   In GL the goals of treatment are to reduce the symptoms of chest pain, breath-  lessness and tachycardia. In the long-term the goal is to improve exercise  capacity and limit risk of onset of a myocardial infarction (heart attack). In  ischaemic heart disease, as the number of coronary arteries with athero-  sclerosis and the extent of occlusion increase, the risk of angina and myo-  cardial infarction increases. Long-term management should consider reducing  atherosclerotic lesions with coronary angioplasty.   During the management of an acute attack of angina, pharmacotherapy is  used to reduce oxygen demand and to improve oxygen supply. In GL iso-  sorbide dinitrate is used. By causing dilation of the coronary veins isosorbide  dinitrate reduces venous return and results in a reduction of cardiac output.  Oxygen supply may be improved by using antithrombotic therapy and  antiplatelet therapy. When patients with ischaemic heart disease feel chest  pain they are usually advised to use sublingual glyceryl trinitrate or glyceryl  trinitrate spray and to take aspirin preferably dispersed in water or chewed  for a more immediate drug release compared with swallowing a tablet. A  single-dose of aspirin of 150-300 mg should be given as soon as possible  after the attack. Patient or carers should inform health professionals what medi-  cation the patient has already taken when symptoms of attack started. Heparin  is used to decrease platelet aggregation.   Isosorbide dinitrate is a coronary vasodilator and side-effects of peripheral  vasodilation may occur. These include flushing, throbbing headache, hypo-  tension and dizziness.   When heparin is administered by intravenous or subcutaneous injection, it has  a rapid onset of action and an average halflife of 1.5 h. There is variability  in halflife ranging between 1 to 6 h depending on a number of factors such  as renal impairment and liver disease. It carries a risk of bleeding and the  patient should be monitored for signs of haemorrhage.   Isosorbide dinitrate is initially given intravenously to achieve a fast onset of  action and response. Once GL is stabilised, and no chest pain is reported,    isosorbide dinitrate is switched to oral administration. This usually requires  24-48 h. Heparin is given to reduce thrombin generation and fibrin formation  and unless there are further complications, treatment is continued for about  48 h. Aspirin is used to reduce the incidence of myocardial infarction and GL  should continue taking aspirin daily as he was doing before the acute attack.   Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that has anti-  hypertensive effects. It is an appropriate choice of antihypertensive in GL as  ACE inhibitors are preferred drugs in diabetic patients. It is very important that  diabetic patients have their blood pressure very well controlled as these  patients have multiple risk factors towards the development of cardiovascular  disease. Also both long-standing uncontrolled hypertension and diabetes  increase the risk of kidney damage. GL had a myocardial infarction two years  earlier. ACE inhibitors have a cardioprotective effect in patients at high risk of  cardiovascular disease, including those who suffered a myocardial infarction.   Metformin is a biguanide which, unlike sulphonylureas, is not associated with  weight gain. It is therefore an appropriate antidiabetic for GL who is obese.  It increases insulin sensitivity and increases the utilisation of glucose. It does  not interfere with insulin release. It may cause lactic acidosis. During treatment  metformin causes conversion of glucose to lactate in the intestinal mucosa;  lactate is transported to the liver where it is normally metabolised. High plasma  concentrations of metformin such as in renal impairment or high lactate  concentrations in blood caused by liver disease and alcohol abuse lead to the  inability by the liver to clear the lactate. Metformin should not be used in renal  impairment, and diabetic patients receiving metformin should have their renal  function monitored to exclude renal function deterioration, which may warrant  withdrawal of metformin.   Metformin increases the use of glucose and increases insulin sensitivity. It is  not associated with onset of hypoglycaemia and it does not cause weight gain.  To decrease gastrointestinal side-effects such as abdominal discomfort,  nausea, diarrhoea and metallic taste, patients are advised to take tablets with  meals. Gastrointestinal side-effects are quite common and in some patients  lead to the patient not accepting treatment with metformin.   ACE inhibitors such as enalapril interfere with the conversion of angiotensin I  to angiotensin II. Angiotensin II is a vasoconstrictor and stimulates aldosterone  release. As ACE inhibitors prevent the formation of aldosterone, they reduce  potassium excretion and may lead to hyperkalaemia. Heparin may also induce  hyperkalaemia because it inhibits aldosterone secretion from the adrenal  glands. Risk of hyperkalaemia is increased in diabetic patients, in patients  with chronic renal failure and in patients taking potassium-sparing diuretics.  Furosemide is a loop diuretic that inhibits sodium, potassium and water  retention in the kidney and its use may precipitate hypokalaemia.   Simvastatin is a statin that is used as a lipid-lowering agent. Use of statins is  recommended in patients with ischaemic heart disease to decrease morbidity  and mortality. They are used to reduce low-density-lipoprotein cholesterol and  slow atherosclerosis. Patient should be advised to follow a diet low in choles-  terol in conjunction with long-term statin therapy. Before initiating statins, liver  function tests should be carried out, as statins are contraindicated in active  liver disease. There is no interaction between statins and non-steroidal anti-  inflammatory drugs.   Glyceryl trinitrate patches should be applied on chest wall, upper arm or  shoulder and replaced daily. For each application, the patch should be placed  on a different area. The patch should be removed at night to provide a nitrate-  free period. This will reduce development of tolerance to glyceryl trinitrate.   GL may be prescribed glyceryl trinitrate spray which can be used for the  prophylaxis of angina when onset of symptoms occur. The patient is advised  to apply one or two doses under the tongue and close mouth. If there is no  response within 10 minutes, the same dose may be repeated. The advantage  of the spray over the sublingual tablets is that sublingual tablets have problems  of stability which require the patient to discard any tablets remaining after  8 weeks from opening.    On admission, MG is taking nifedipine, a calcium-channel blocker and aspirin  as an antiplatelet agent. He is admitted with a stroke, a cerebrovascular  accident that is occlusion of a cerebral artery by an embolus in the brain or  cerebrovascular haemorrhage. The condition leads to ischaemia of the brain  tissues. The location and extent of ischaemia have an impact on the sequelae  of the attack. Paralysis, speech impairment or death may occur. In MG, hyper-  tension is a major predisposing factor for stroke. Other factors that increase  risk of stroke include age, diabetes, transient ischaemic attacks and previous  stroke. MG is admitted to hospital to be given support and medical manage-  ment of the acute phase of the stroke. The use of antiplatelet agents in the  management of a non-haemorrhagic stroke is the main line of treatment aimed  at preventing formation of thrombi in the arterial vessels. Aspirin is indicated  to be used immediately after a non-haemorrhagic cerebrovascular event.  Aspirin has antiplatelet effects as it irreversibly inhibits cyclo-oxygenase, which  in platelets is responsible for the conversion of arachidonic acid into    thromboxane A 2 which is a vasoconstrictor and stimulates platelet aggrega-  tion. Dipyridamole may be used in combination with low-dose aspirin to  reduce the risk of recurrent stroke.   Dipyridamole is an adenosine reuptake inhibitor and a phosphodiesterase  inhibitor which has antiplatelet and vasodilating properties. It is given in oral  doses of 300-600 mg daily in divided doses. It is incompletely absorbed from  the gastrointestinal tract and therefore it should be administered before food.  Dipyridamole should be used with caution in patients with hypotension, heart  failure, rapidly worsening angina, aortic stenosis and myocardial infarction.  It is essential to avoid hypotension, to maintain systemic circulation and to  avoid orthostatic changes in patients with an acute stroke, as compromised  blood supply to the brain may precipitate degeneration of the condition.   The most common side-effects to be expected from dipyridamole are gastro-  intestinal effects such as nausea, abdominal pain, constipation, dizziness,  throbbing headache, hypotension, hot flushes and tachycardia. Risk of occur-  rence of constipation is higher in hospitalised patients and in patients with  limited mobility.   Nifedipine is a dihydropyridine calcium-channel blocker. It has predominant  activity as a peripheral and coronary arteries vasodilator. As it has minimal  effect on cardiac conduction and negative inotropic effect is very low at thera-  peutic doses, it rarely precipitates heart failure. It is used in the management  of hypertension and for the prophylaxis of angina.   Nifedipine is rapidly and efficiently absorbed from the gastrointestinal tract  but undergoes an extensive first-pass effect. Following oral administration of  normal release tablets, it has a halflife of about 2 h. Use of normal-release  tablets in the management of hypertension leads to large variations in blood  pressure as a three-times-daily dosage regimen would still leave periods during  which blood pressure is not controlled. Also, occurrence of reflex tachycardia  is higher. Modified-release preparations are preferred and in fact MG was  receiving modified-release tablets of 20 mg three times daily. Bioavailability  of slow release formulations is lower than conventional tablets.   Blood pressure should be monitored in MG. Hypertension should be controlled  and development of hypotension avoided. Heart rate and signs and symptoms  of heart failure such as oedema should be monitored.    GX is receiving glibenclamide (sulphonylurea), isosorbide mononitrate  (nitrate), aspirin (antiplatelet), perindopril (angiotensin-converting enzyme  inhibitor), calcium supplement and cod liver oil capsules. From this medication  review it can be understood that GX is receiving treatment for the manage-  ment of diabetes and cardiovascular disease. All the medications except for  glibenclamide are prescribed as a single daily dose. For isosorbide mono-  nitrate 60 mg slow-release tablet is prescribed.   Glibenclamide is a second-generation sulphonylurea that has a duration of  effect of 20-29 h but which may be even longer in older people. Its use in  GX should be undertaken with care as the risk of hypoglycaemic attacks is    higher than other sulphonylureas such as gliclazide and glipizide. Hypo-  glycaemia may lead to confusion, unconsciousness and coma if no immediate  intake of glucose is taken. This is of concern for GX who lives on her own.  According to this medication profile, GX is taking quite a high dose of gliben-  clamide. The usual recommended dose of glibenclamide is 5 mg at breakfast  to a maximum of 15 mg daily. The dose of glibenclamide and suitability of  the drug for GX should be discussed with the prescribing team.   An advantage of angiotensin-converting enzyme (ACE) inhibitors such as  perindopril is that they do not interfere with glucose tolerance and they can  be used as antihypertensive agents or for the management of heart failure in  diabetic patients. A maximum daily dose of 8 mg of perindopril may be recom-  mended. Deterioration in renal function, which can be monitored by  measuring blood urea and creatinine concentrations, may occur, especially in  patients who have existing kidney disease and heart failure. Monitoring  parameters to be measured in GX should include renal function.   Isosorbide mononitrate is an active metabolite of isosorbide dinitrate. Advan-  tages over isosorbide dinitrate include a higher bioavailability after oral  administration as it does not undergo first-pass hepatic metabolism and a  longer halflife. Isosorbide mononitrate is used in the prophylaxis of angina  and in congestive heart failure.    AV is receiving treatment for rheumatoid arthritis. This is a chronic, progress-  ive inflammatory disease that leads to articular and extra-articular symptoms  which present significant morbidity to the patient. The condition reduces  life expectancy. AV is receiving a disease-modifying antirheumatic drug,    methotrexate and prednisolone, as an anti-inflammatory agent. She is also  receiving folic acid, calcium and vitamin D supplements and disodium  pamidronate, which is a biphosphonate. In rheumatoid arthritis, aims of  treatment are to decrease disease progression, limit morbidity and decrease  occurrence of flare-ups.   Rheumatoid arthritis is associated with inflammation of the synovial membrane  of different joints. It is not a localised condition and affects different joints  commonly in the hands, wrists, knees, feet and shoulders. Trigger factors are  not clear but there is evidence that the condition is immune-mediated.   There is great inter-patient variation in the course of the disease. Onset is  insidious and the disease usually presents initially with non-specific symptoms  such as fatigue, malaise, diffuse musculoskeletal pain and stiffness. Charac-  teristically, at onset the patient presents with symmetrical small-joint polyarthri-  tis in the hands, wrists and feet. Diagnostic criteria for rheumatoid arthritis  include presence of morning stiffness, presence of arthritis in three or more  joints, symmetrical involvement, rheumatoid nodules, serum rheumatoid factor  and radiographic changes.   As rheumatoid arthritis progresses, morning stiffness becomes prolonged and  more disabling, interfering with patient's daily activities. When assessing  outcomes of therapy, functional assessment and impact on the patient's lifestyle  should be considered. Factors to be taken into account include duration of  morning stiffness, the patient's ability to dress and carry out daily activities,  and grip strength.   As rheumatoid arthritis is a chronic inflammatory disease, patients may  develop anaemia. This occurs because of reduced erythropoiesis during  inflammatory disease. The use of prednisolone for long periods may cause  peptic ulceration with perforation leading to gastrointestinal bleeding, which  may be another cause for anaemia. Methotrexate may also cause intestinal  ulceration and bleeding. Development of signs and symptoms of gastric irri-  tation and ulceration should be monitored and AV should be asked to report  any gastrointestinal effects. Measurement of creatine kinase (CK) is indicated  in the diagnosis of myocardial infarction, neurological or skeletal muscle  disease.   In AV methotrexate is prescribed as a weekly dose of 15 mg. It is very  important to advise AV about proper administration of the drug and the  pharmacist should ensure that the patient has understood the dosage regimen.  Fatalities may occur if patients inadvertently take the drug at this dose daily.  Methotrexate is considered to be a first-line drug in the management of  rheumatoid arthritis and the usual maximum dose is 15 mg once a week. AV  is given folic acid to reduce nausea and stomatitis, which may be side-effects  of methotrexate. It is also given as a once weekly dose, and to aid compli-  ance the patient is advised to take folic acid the day after methotrexate  administration. Methotrexate may cause bone marrow suppression and  therefore patients are more prone to develop infections. AV should be advised  to report immediately any signs of an infection such as sore throat or fever.  Methotrexate may also cause pulmonary toxicity, and patients should be asked  to report cough and dyspnoea. Bone marrow suppression may be further  increased by long-term administration of prednisolone, a glucocorticoid. As  both methotrexate and prednisolone may cause gastrointestinal ulceration, AV  should be advised to take tablets after food.   As methotrexate may cause bone marrow suppression, the patient should have  a full blood count, including differential white cell count, regularly. If signifi-  cant leucopenia or thrombocytopenia occurs, treatment should be stopped as  the condition may be fatal. Renal function should also be monitored, as the  use of methotrexate in moderate or severe renal impairment is not recom-  mended. Methotrexate may cause liver cirrhosis, and liver function tests should  be carried out regularly. AV should be advised to avoid alcohol to lower her  risk of hepatic damage.   Disodium pamidronate is a biphosphonate that may be used in the prophyl-  axis and treatment of osteoporosis and corticosteroid-induced osteoporosis.  AV is receiving prednisolone as a long-term medication to suppress symptoms  of the disease. Discontinuation of treatment may lead to flare-ups of the  condition. Long-term use of corticosteroids is associated with onset of osteo-  porosis, diabetes and hypertension. AV is a post-menopausal woman who is  at a higher risk of developing osteoporosis, compared with the normal female  cohort group, as she is also receiving prednisolone long-term therapy. In AV  disodium pamidronate is used to counteract corticosteroid-induced osteo-  porosis. A disadvantage of disodium pamidronate is that it is only available  for slow intravenous infusion, which is given every 3 months, requiring the  patient to be hospitalised for about 3 h. Its use may lead to hypocalcaemia  and serum electrolytes should be monitored. Other biphosphonates such as  alendronic acid and risedronate, which are available as once weekly oral  formulations, may be considered as an alternative. AV is receiving calcium  and vitamin D supplementation to prevent hypocalcaemia and as bone  supplements in the management of osteoporosis.    Disease-modifying antirheumatic drugs include cytokine inhibitors such as  etanercept and infliximab. These two drugs inhibit tumour necrosis factor,    which is an inflammatory mediator that contributes to synovitis and joint  destruction in rheumatoid arthritis. Both drugs are available for parenteral  administration. They are recommended for use in rheumatoid arthritis when  other disease-modifying antirheumatic drugs have failed to achieve symptom  control. As they have been associated with the onset of severe infections,  including tuberculosis, patients should be evaluated for tuberculosis before  treatment and asked to report any signs of infection.    MA suffered an acute attack of shingles, which is caused by the virus herpes  zoster. The condition is associated with a unilateral rash and the patient  complains of pain which may continue after the rash has disappeared, leading  to postherpetic neuralgia.   Shingles occurs as a result of reactivation of the varicella zoster virus that is  dormant in the nuclear DNA of dorsal root ganglia. Reactivation of the virus  may occur as a result of a reduction of the host immunity. The virus tracks  down the nerve axon to cause a skin infection in the area innervated by the  sensory nerve and this is characterised by vesicular eruptions.   Shingles usually occurs along the thorax, head and neck and lumbosacral  area. Eye or ear involvement may occur and this requires referral of the patient  to a specialist to limit long-term damage. Postherpetic neuralgia may develop  as a chronic painful condition that may last from months to years after the  acute phase of shingles. Postherpetic neuralgia presents with severe, con-  tinuous, burning pain.   Famciclovir is a prodrug of penciclovir. Famciclovir is rapidly absorbed from  the gastrointestinal tract following oral administration and it is converted to  penciclovir. Penciclovir itself is poorly absorbed from the gastrointestinal tract.  Famciclovir has better bioavailability (70%) compared with aciclovir (30%)  after oral administration. For this reason famciclovir and valaciclovir, which is  a prodrug of aciclovir, require less frequent dosing compared with aciclovir  in the management of shingles. MA was receiving famciclovir 250 mg tablets  three times daily during the acute phase.   Use of antiviral drugs such as famciclovir at the onset of the acute phase  reduces the risk of postherpetic neuralgia. Famciclovir should be continued for  7 days. MA has finished the treatment with famciclovir.   Side-effects associated with famciclovir are rare and these include nausea,  headache, confusion, vomiting, jaundice, dizziness, drowsiness, halluci-  nations, rash and pruritus.   As the rash has disappeared and MA is still feeling pain, he has developed  postherpetic neuralgia. Occurrence of severe pain during the acute phase is  associated with an increased likelihood that the patient develops postherpetic  neuralgia.   Drugs which could be recommended for MA include analgesics such as non-  steroidal anti-inflammatory drugs, for example, ibuprofen. They may provide  some pain relief. Patient should be advised to take medication with food and  they should not be used if MA has a history of peptic ulcer disease or asthma  or if he is on anticoagulant therapy. Tricyclic antidepressants such as amitripty-  line may be used as an adjunct analgesic drug that is administered at night  to alleviate pain and also induce sedation. If the patient still complains of pain,  then anticonvulsants such as carbamazepine and gabapentin may be used.   headings followed by a list of numbered questions. For each  numbered question select the one heading that is most closely  related to it. Each heading may be used once, more than once,  or not at all.   Select, from A to I, which one of the above is used:    Directions: For each of the questions below, ONE or MORE of the   responses is (are) correct. Decide which of the responses is  (are) correct. Then choose:    A □ if 1 , 2 and 3 are correct  B □ if 1 and 2 only are correct   3 □ CK-MB are detected in blood within 3-5 h of a myocardial   2 □ measures the rate at which red blood cells settle out of   1 □ not to take product at the same time as other drugs, except   Q13 Patients should be advised to avoid direct sunlight when taking:   3 □ are less likely to be associated with hypersensitivity reactions   1 □ may occur in association with inflammation of the sinuses   2 □ liver damage may occur, requiring a liver transplant to   3 □ the aim of treatment is to achieve clearance of the virus   which is sustained for at least 1 month after treatment has  stopped   Q17 It is recommended that long-term therapy for patients presenting with  stroke should consider use of:   Q1 8 In patients with stage III (Duke's C) colon cancer, the choice of adjuvant  chemotherapy should take into account:    Q19 The use of calcium supplementation to reduce risk of fractures:   1 □ is associated with poor compliance because of the need for   3 □ consists of calcium lactate as it is the only salt that can be   2 □ can be corrected by using concave lenses for spectacles or   3 □ occurs when the person cannot clearly see an object that is   Q21 Patients who are following a low-fat diet should be advised to:   3 □ that the skin is more susceptible to microbial colonisation   Q23 Measurement of drug plasma concentrations is recommended when  patients are started on:   Q25 Immunosuppressive agents that may be used after kidney transplanta-  tion include:   patient profile and answer the questions. For each of the  questions below, ONE or MORE of the responses is (are)  correct. Decide which of the responses is (are) correct. Then  choose:    A □ if 1, 2 and 3 are correct  B □ if 1 and 2 only are correct   U is a 66-year-old female who was admitted to the medical ward for the  management of atrial fibrillation.   PMH hypertension, asthma  DH potassium chloride one tablet daily  bendroflumethiazide 5 mg daily  warfarin 3 mg daily  O/E blood pressure 21 0/95 mmHg   On hospitalisation, digoxin was started at a loading dose of 0.25 mg daily and  perindopril 2 mg nocte.   Q28 Drugs that could alter QT interval in an ECG include:   Q30 The reasons why digoxin was preferred to other options are:   3 Q perindopril is being used as a prophylactic of cardiovascular   Q34 The medication review once the patient is stabilised should assess the  need for continuation of treatment with:   AX, a 72-year-old male was referred to casualty because of a 3-week history of  fever and painful joints. He presents with an increased swelling and warmth in  hands, wrists and ankles. The patient was being well controlled on methotrexate  1 5 mg weekly up to the last visit to the rheumatology clinic four weeks ago.   methotrexate 1 5 mg weekly  folic acid 10 mg weekly  paracetamol 1 g 8 hourly/pm  Drug allergies leflunomide   O/E swollen, warm, tender R and L hand, R and L wrist, R and L ankles   spindling of digits and wasting of small muscle of hand  Investigations ECG: normal  CXR: normal   RBC: 3.9 X 1 0 12 /l (4.4-5.8 X 1 0 12 /l)  platelets: 250 X 1071 (150-400 X 1071)   On admission to the ward AX was administered methlyprednisolone 500 mg by  slow intravenous infusion for one day.   Q40 The interpretation of the results of the blood glucose tests for AX:    Q41 In the long-term, drugs that could be considered as additional treatment  to methotrexate for the management of rheumatoid arthritis in AX  include:   MB is a 55-year-old male who presented to the emergency department  complaining of palpitations. His blood pressure was found to be 1 50/1 10 mmHg.  Patient stated that he was previously admitted to hospital with hypertension. On  questioning he said that he was on moxonidine 200 pg twice daily but that he had  stopped the medication because he had run out of tablets. The patient said that he  was used to having high blood pressure but never suffered from palpitations.   3 □ should not be used in patients hypersensitive to ACE    Q4f Other drugs that have a similar mode of action to moxonidine include:   RB is a 30-year-old female with a history of systemic sclerosis admitted for  treatment of acute Raynaud's phenomenon.   PMH 9-year history of Raynaud's disease with discoloration and cyanosis of  fingers on exposure to cold temperatures.   Left index fingertip is swollen and red, mild tenderness and loose nail. The thumb is  swollen and tender. There is mild erythema with a small amount of clear discharge  beneath the nail fold.   3 □ should not be used for longer than 6 weeks   Q5I Drugs that should be used with caution or avoided in RB include:   1 □ has more influence on the myocardium than on peripheral   FG is an 83-year-old female presenting with a sudden episode of shortness of  breath and retrosternal chest pain. She said she was having occasional cough and  whitish sputum. Symptoms were accompanied with cold sweat, slight nausea but  no vomiting. No abdominal pain and no fever have been reported.   PMH diabetes mellitus controlled by diet, hypertension, congestive heart failure,  depression   potassium chloride 600 mg tds  verapamil 40 mg tds  dipyridamole 25 mg daily  bumetanide 1 mg daily  multivitamins one tablet daily  SH lives with elderly sister  O/E BP: 148/90 mmHg  pulse: 70 bpm  temperature: 35.5°C  chest: creps up to apices bilaterally  abdomen: soft, non-tender  ° oedema, ° DVT   Investigations ECG: ST depression and T wave flattening  CXR: cardiomegaly  Na 136(1 35-1 45 mmol/l)   WBC: 16 X 1 0 9 (5-1 0 X 1 0 9 /I)  glucose 19.1 mmol/l (<7.8 mmol/l)   2 □ should be used with caution in rapidly worsening angina   AP is a 71 -year-old female with a history of hypertension, diabetes mellitus,  ischaemic heart disease and congestive heart failure. A year ago she had a  myocardial infarction.   Patient presents with 3-day history of central compressive chest pain radiating to  epigastrum that is associated with sweating and belching. No nausea, vomiting,  shortness of breath and palpitations are reported. Pain started at rest, occurs on  and off and worsens on exertion, especially when going upstairs. Patient claims the  pain is very similar to previous myocardial infarction pain episode.   ECG showed T wave inversion. CK was 265 (<1 75 U/l).   SH married, lives with husband. Non-smoker, no alcohol. Father died at 58  and had a history of diabetes and ischaemic heart disease, mother was  diabetic.   O/E heart sounds normal  chest X-ray normal  few bibasal creps  abdomen is soft, non-tender  no left leg calf tenderness  mild pitting oedema  no signs of DVT  BP: 1 30/80 mmHg  pulse 68 bpm   DH candesartan 16 mg daily  clopidrogel 75 mg daily  isosorbide mononitrate 60 mg daily  fluvastatin 80 mg nocte    amlodipine 10 mg daily  carvedilol 6.25 mg bd  bumetanide 1 mg tds   3 □ should be used with caution in renal artery stenosis   3 □ a complete blood count should be carried out before starting    KB, a 36-year-old female, presents with complaints of dysuria, urinary urgency  and increased frequency.    SC, a 34-year-old female in her first month of pregnancy, was diagnosed as  having a blood pressure of 140/100 mmHg. Full examination showed that all  other investigations were normal. She was started on labetalol 100 mg daily.   Q73 Du ring pregnancy, antihypertensives that should be avoided or used  with caution include:   1 □ acts as a competitive antagonist to alpha and beta receptors   HG, a 46-year-old female presents with complaints of a troublesome cough at  night, nasal congestion and nasal itchiness. The symptoms have been present for  the past weeks. She states that she has nasal allergy most of the time but now the  condition seems to have deteriorated.   She has been using oxymetazoline spray two puffs three times a day for the past  two weeks. She has tried to use some tablets previously but has stopped them.   2 □ the patient should be advised to stop using it   1 □ is indicated in this patient on a long-term basis    Medical devices are used for the diagnosis and monitoring of diseases.  Accuracy and reliability of the device may vary and reflect on the product's  costs. Specifications for medical devices may depend on their intended use.   An ophthalmoscope is used to examine the fundus of the eye, which consists  of the retina, retinal vessels, sclera, optic disk and choroids. It can be used to  diagnose and assess the progression of retinopathy where retinal changes  occur. Retinopathy could be brought about by hypertension or diabetes.   A stethoscope may be used for auscultation of heart sounds or breath sounds.  Abnormal breath sounds such as wheezes and bronchial breath sounds may  occur with airways obstruction or respiratory tract infections.   A reflex hammer is used to evaluate deep tendon reflexes. It is used to assess  damage to the spinal reflex arc such as after a cerebrovascular accident.    An understanding of the control of hormones and mechanisms that affect their  production and release is essential to understand the pathology of the disease  states that are related to the endocrine system.   Human chorionic gonadotrophin is a hormone that is secreted by trophoblastic  cells in the placenta and is excreted in the urine of pregnant women. It  stimulates the corpus luteum to secrete oestrogen and progesterone and to  decrease lymphocyte activation. Its presence in urine is used as the indicator  for pregnancy in pregnancy tests.   C peptide is an inactive residue of insulin formation in the beta cells of the  pancreas. It is degraded in the kidney. Measurement of serum C peptide may  be used in diabetic patients who are being treated with insulin and who have  anti-insulin antibodies. Diminished kidney function may lead to increased  amounts of C peptide in serum.   Prolactin is a hormone that is produced by the anterior pituitary gland. In  conjunction with other hormones such as oestrogen and progesterone, it  stimulates development of mammary glands. After parturition, it stimulates and  maintains breast milk production. Prolactin blood levels are used in the  diagnosis of prolactin-secreting pituitary adenomas.   Creatine kinase (CK) is an enzyme that is found in heart muscle, skeletal muscle  and the brain. There are three isoenzymes: CK-BB (CPK1) which is pre-  dominantly found in the brain and lungs, CK-MB (CPK2) mainly found in myo-  cardial cells and CK-MM (CPK3) which consists of circulatory CK. Creatine  kinase blood levels rise when these muscle or nerve cells are injured.    Differential elevations of the three isoenzymes indicate the type of tissue that  has been damaged. A rise in CK-BB occurs after a cerebrovascular accident  or pulmonary infarction. CK-MB is elevated after a myocardial infarction and  in unstable angina. However, severe skeletal muscle injury may also elevate  CK-MB. CK-MM levels are increased in myopathies, after vigorous exercise or  surgery.   Auscultation of bowel sounds is undertaken to identify bowel obstruction or  ileus. Ileus is a condition where there is an obstruction of the intestines resulting  from immobility or mechanical obstruction. Ileus may be due to opioid drugs  and could occur postoperatively because of the administration of opioid drugs  and anaesthesia. After a surgical intervention, bowel sounds are monitored  using a stethoscope to eliminate ileus. Normal bowel sounds indicate peristal-  sis and may be audible without the use of a stethoscope.   A complete blood count (CBC) is a series of tests on a blood sample to present  red blood cell count, haemoglobin level, haematocrit, red blood cell indices  (mean corpuscular volume, mean corpuscular haemoglobin, mean corpuscu-  lar concentration), white blood cell count and differential count for different  components, blood smear and platelet count.   The erythrocyte sedimentation rate (ESR) is a non-specific test that indicates  conditions of inflammation, infection, malignancy and tissue necrosis or infarc-  tion. The test is a measure of the rate at which red blood cells settle out of  mixed venous blood over a specified period. The test requires that a blood  sample is aspirated into a calibrated sedimentation tube and blood is allowed  to settle usually for 60 minutes. ESR together with other indicators may be used  to evaluate disease progression.   Gastro-oesophageal reflux disease (GORD) is usually due to reflux oesophagi-  tis, which results in acid regurgitation. Stomach contents which have a low pH  are refluxed into the oesophagus and the oesophageal mucosa has very little,  if any, protection against acidic contents. Dysphagia, which is difficulty in  swallowing, may sometimes occur in GORD. Stricture formation of the oeso-  phagus may take place in GORD, owing to the inflammation caused by acid  regurgitation.   A mixture of magnesium hydroxide and aluminium salts in antacid prepara-  tions is referred to as co-magaldrox. Antacid preparations are used for the  symptomatic management of dyspepsia, gastro-oesophageal reflux and  gastric pain. Patients are advised to use the preparation after meals and at  bedtime when required. Co-magaldrox preparations have the advantage that  they eliminate the side-effects of magnesium salts (diarrhoea) and aluminium  salts (constipation) as they cancel each other out. Patients should be advised  not to take antacid preparations at the same time as other medications as  antacids may impair absorption of the other drugs. Antacids may damage  enteric-coated tablets, resulting in the dissolution of the drug in the stomach,  thus defeating the purpose of using an enteric-coated formulation.   Some drugs may cause phototoxic or photoallergic reactions if the patient is  exposed to ultraviolet light. When patients taking amiodarone (for arrhyth-  mias) are exposed to direct sunlight or to sun lamps, photosensitivity may occur  owing to a phototoxic reaction. A skin reaction may occur and this may  continue for some weeks after treatment when amiodarone is stopped. Patients  using amiodarone should be advised to use total sunblock preparations, to  wear protective clothing and to avoid exposure to sun.   Immunoglobulins are used in clinical practice to induce passive immunity and  therefore to present immediate protection against an infectious disease.  Human immunoglobulins may be of two types: normal immunoglobulin or  specific immunoglobulins. Normal immunoglobulin presents antibodies  against several infectious diseases, whereas specific immunoglobulins present  a specific antibody such as hepatitis B immunoglobulin. Human immuno-  globulins are prepared from pooled plasma or serum of human donors. The  human donor material is tested for presence of hepatitis B surface antigen and  for antibodies against hepatitis C virus and human immunodeficiency virus.  Human immunoglobulins are preferred to antisera (immunoglobulins) as they  are associated with a lower incidence of hypersensitivity reactions.   Glue ear, also referred to as sero-mucinous otitis media, is a condition where  there is an accumulation of viscous mucous fluid in the middle ear, usually  occurring after repeated attacks of acute otitis media. It occurs most commonly  in children. Glue ear may also be found in association with inflammation of  the sinuses and blockage of the eustachian tube. Deafness or difficulty in  hearing is usually the presenting symptom and in some cases this may go  unnoticed and lead to permanent hearing loss.   Hepatitis C is a viral infection that is transmitted through contact with contam-  inated blood such as when sharing needles and through intravenous drug  misuse or the transfusion of infected blood. In hepatitis C, the aim of treatment  is to achieve the clearance of the virus, which is sustained for at least 6 months  after treatment has stopped. This reduces the risk of cirrhosis and hepato-  cellular carcinoma. Patients may require a liver transplant to prevent death  caused by cirrhosis. Interferon alfa is used in combination with ribavirin  (antiviral drug). Peginterferon alfa consists of a polyethylene glycol-conjugated    derivative of interferon alfa. Pegylation results in increasing the availability of  interferon in blood and therefore halflife is extended so that the dosing  frequency that is required is reduced.   A stroke, also referred to as a cerebrovascular accident, is due to acute neuro-  logical dysfunction of vascular origin in focal areas of the brain. It may present  as a completed stroke, where the signs and symptoms occur for more than  24 h, or a transient ischaemic attack if the signs disappear within a few  minutes or at most within 24 h. Patients with transient ischaemic attacks or  stroke are at an increased risk of further stroke, myocardial infarction or  sudden death. Pharmacotherapy that could be used to prevent these sequalae  include long-term prophylaxis with daily aspirin. An angiotensin-converting  enzyme (ACE) inhibitor should be considered, especially in patients with  hypertension, to reduce blood pressure and for the prophylaxis of cardio-  vascular events. Hypercholesterolaemia is a risk factor for atherosclerosis  and cardiovascular disease. Statins may be considered to decrease plasma-  cholesterol concentrations.   Colorectal cancers may be classified according to the Duke's classification,  which was originally described in 1932, or according to the TNM classifi-  cation. A stage III or a Duke's C tumour implies that tumour cells have invaded  the musculature and that there is lymph node involvement. There is a 10-40%  chance of a 5-year survival rate. Patients with stage III colorectal cancer should  receive adjuvant chemotherapy to decrease the high risk of recurrence. Choice  of adjuvant chemotherapy is based on a risk-to-benefit ratio for the individual  patient who is usually asymptomatic after tumour resection. Side-effects and  the method of administration should be taken into account when deciding  which drugs to use. Drugs that do not require an invasive administration, such  as drugs presented in oral formulations - for example, capecitabine - are  preferred to drugs that require lengthy intravenous infusions such as irinotecan.   Calcium supplementation increases net calcium absorption and decreases  bone turnover. Many adults are in negative calcium balance throughout their  lives, an imbalance that worsens with age and increases the risk of osteo-  porosis and bone fracture. Calcium supplementation presents calcium salts as  tablets, chewable tablets or effervescent tablets. The patient is required to take  a sustained daily intake of the calcium supplement for a prolonged time. Poor  compliance is quite common with individuals stopping intake or taking the  supplementation intermittently. Products containing calcium and vitamin D may  be used in the management of osteoporosis to prevent fractures. Cacitriol, a  metabolite of vitamin D, enhances the absorption of calcium from the small  intestine. Different calcium salts may be used for supplementation such as  calcium lactate, calcium carbonate and calcium gluconate. Calcium carbonate  has the highest calcium content per gram of salt.   Myopia is an ophthalmic condition resulting in parallel rays being focused in  front of the retina. It may be caused by an elongation of the eyeball or by an  error of refraction. The condition is also called nearsightedness or shortsighted-  ness as affected individuals cannot clearly see objects that are more than a  metre from the eye. Concave lenses for spectacles or contact lenses are used  to correct the error.   Patients following a low-fat diet should be advised to increase fibre intake  which is found in fruits, green leafy vegetables, root vegetables, cereals and  breads. This will increase satiety and may interfere with fat absorption due to  adsorption with fat molecules. Saturated fat is found mainly in food of animal  origin such as beef, pork, lamb and whole-milk products. A diet high in  saturated fats results in high serum cholesterol levels and high serum low-  density lipoprotein cholesterol levels. Polyunsaturated fat is predominantly    present in fish, corn, sunflower seeds, soybeans and walnuts. Patients  following a low-fat diet should restrict their intake of saturated fats and concen-  trate more on polyunsaturated fat.   Atopic eczema is a skin condition characterised by pruritus and inflammation.  A prominent feature is dry skin. Atopic eczema may become infected because  of the patient scratching the area, which is intensely pruritic. The skin is more  susceptible to microbial colonisation because of dehydration and inflamma-  tion. Patients should be advised to avoid scratching the area and to use  emollients and emollient bath oils instead of regular soap and bubble baths  when bathing. These can be used and applied as needed.   Phenytoin is an antiepileptic drug that has a narrow therapeutic drug index.  Monitoring of plasma concentrations is used to reduce phenytoin toxicity by  assessing that the plasma concentration is within the therapeutic range. It is  particularly useful when patient is started on the treatment, during dose adjust-  ments to achieve seizure control or when the patient complains of side-effects  that may be attributed to high plasma concentrations of phenytoin. In cancer  chemotherapy, side-effects, particularly neutropenia and other specific side-  effects such as cardiac toxicity for doxorubicin, are the dose-limiting  parameters that are used. Alteplase is a fibrinolytic drug that is used as quickly  as possible in myocardial infarction, stroke and pulmonary embolism.  Alteplase is a glycosylated protein and it is cleared rapidly from plasma mainly  by metabolism in the liver.    Irritable bowel syndrome is a condition where patients complain of diarrhoea  or constipation, abdominal pain and bloating. The condition may impact    negatively on the patient's social life as they may feel that their symptoms  restrict their activities. The condition may be associated with stress and  depression.   Kidney transplantation is necessary when there is irreversible failure of the  kidney. There are a number of complications associated with this intervention,  including donor identification, organ preservation and organ rejection.  Immunosuppressive agents are used to promote acceptance of the donor  organ, while maintaining as much as possible a functional immune system.  Azathioprine, prednisolone, which is a corticosteroid, and ciclosporin are  used in kidney transplantation to prevent organ rejection.   Anaemia in cancer patients may be chemotherapy-induced or may be due to  the tumour. The tumour may result in bone marrow infiltration or lead to gastro-  intestinal blood loss. The process of development of anaemia in cancer  patients may not be clearly understood. Anaemia develops insidiously. It may  be corrected with the use of human recombinant erythropoietin, particularly if  it is chemotherapy-induced. Erythropoietin and darbepoetin, which is the  hyperglycosylated derivative of erythropoietin, are used to correct anaemia.    On admission, LJ is taking bendroflumethiazide (thiazide diuretic), warfarin  (anticoagulant) and potassium chloride supplements to counteract potassium  loss brought about by the thiazide diuretic. She has a past history of hyper-  tension and asthma and she is admitted with atrial fibrillation. Atrial fibrilla-  tions are cardiac arrhythmias characterised by disorganised electrical activity  in the atria. Clinical symptoms include shortness of breath, irregular pulse,  dizziness, acute syncopal episodes and heart failure symptoms. Treatment    goals are restoration of sinus rhythm and prevention of further recurrences.  On admission she is started on digoxin (cardiac glycoside) and perindopril  (angiotensin-converting enzyme inhibitor).   Atrial fibrillation is a supraventricular arrhythmia that may be precipitated  by cardiovascular disease that causes atrial distension, such as hypertension,  ischaemia and infarction. It represents a chaotic, disorganised atrial activa-  tion. Ventricular premature beats constitute a form of ventricular arrhythmias.   An electrocardiogram may be undertaken for U to confirm the nature of the  arrhythmias, and 24-h recordings may be preferred to allow monitoring. Drugs  such as amitriptyline (tricyclic antidepressant) and lithium (antimanic drug) may  interfere with the QT interval which represents the time between depolarisa-  tion and repolarisation of the ventricles. Selective serotonin re-uptake inhibitors  such as fluoxetine are not associated with prolonged QT intervals.   Occurrence of atrial fibrillation increases the risk of stroke and heart failure.   In atrial fibrillation, the ventricular response results in a rapid ventricular rate.  Digoxin is a cardiac glycoside that may be used in the management of atrial  fibrillation to control ventricular response. Beta-blockers are used to control the  ventricular rate. They should be avoided in U as she has a past history of  asthma. Beta-blockers should be used with caution in asthma as they may  cause bronchospasms. Digoxin increases the force of myocardial contraction    and decreases conductivity in the atrioventricular node. It does not interfere  with blood pressure.   Digoxin has a narrow therapeutic range but plasma concentration is not the  only factor indicating risk of toxicity. There is inter-individual variability in the  sensitivity of the conducting system or the myocardium to digoxin. Lower doses  should be started in elderly patients and the drug should be used with care  as a decreased renal elimination may result in toxic effects. Digoxin should  also be used with care in renal impairment and in patients who recently have  had an infarction. In renal impairment, the electrolyte disturbances associated  with renal disease such as hypokalaemia predispose to toxicity. Caution  should be employed with its use following a myocardial infarction because of  increased sensitivity of the myocardium.   When U is hospitalised, serum potassium levels should be checked and  monitored to avoid occurrence of hypokalaemia. In U hypokalaemia may  precipitate further arrhythmias, and increases the risk of digoxin toxicity.  Plasma digoxin concentration is useful to ensure that the dose results in a  plasma concentration that is within the therapeutic range and therefore the risk  of toxicity is minimised. The ventricular rate at rest should be monitored to  assess outcomes of therapy and to assess ventricular response to atrial fibril-  lation.   U is started on perindopril because she has uncontrolled blood pressure.  Angiotensin-converting enzyme (ACE) inhibitors are preferred to beta-blockers  in patients with asthma. For the management of hypertension, the recom-  mended initial dose is 4 mg daily. U was started on a lower dose because    she is an elderly patient and she is receiving bendroflumethiazide, which is a  diuretic. U is more at risk of developing first-dose hypotension. The dose is  given at night to limit injuries associated with hypotension.   ACE inhibitors such as perindopril cause potassium retention because they  inhibit secretion of aldosterone. They should not be used concurrently with  potassium supplements and potassium-sparing diuretics as there is a risk of the  development of hyperkalaemia, which should be avoided particularly in U as  it poses a risk of cardiac rhythm disturbances, namely ventricular fibrillation  and cardiac asystole. Perindopril should be continued for the management of  hypertension. Sustained hypertension in U may have precipitated atrial fibril-  lation and may precipitate other cardiovascular conditions. Warfarin therapy  should be continued as patients with chronic atrial fibrillation are at risk of  developing embolism that may lead to stroke and death. In U the use of aspirin  is not indicated as it may precipitate an asthmatic attack.    AX presents with symptoms of rheumatoid arthritis flare-up. On admission, AX  is receiving methotrexate as a disease-modifying antirheumatic drug, fluva-  statin (statin), folic acid and paracetamol as required. Clinical laboratory  investigations are normal except for a slight depression in the red blood cell  count. Further investigations are required before a cause of anaemia can be  established. The red blood cell count may be repeated and haemoglobin levels  measured. AX has a previous history of peptic ulceration and colonic polyps  in addition to rheumatoid arthritis. AX is administered methylprednisolone for  one day.   Rheumatoid arthritis is a progressive disease that is associated with deterio-  ration in patient mobility and a reduction in life expectancy of 7 years in males    and 3 years in women. The aims of treatment in rheumatoid arthritis are to  relieve pain, inflammation and symptoms of flare-ups, to prevent joint destruc-  tion and to preserve functional ability so that the patient can lead as normal  a lifestyle as possible.   Monitoring of outcomes of therapy and of disease progression includes  biochemical tests where changes in inflammatory markers are followed.  Biochemical tests that are undertaken include the measurement of C-reactive  protein (CRP), erythrocyte sedimentation rate (ESR), rheumatoid factor and  antinuclear antibodies. These markers are not specific to rheumatoid disease  and so changes in levels may be experienced when patient has an inflamma-  tory condition.   In AX, methylprednisolone is administered by slow intravenous infusion as a  single dose to control symptoms associated with the flare-up and to induce  remission. It has glucocorticoid effects resulting in an anti-inflammatory action  due to suppression of cytokines. Administration, especially parenteral, results  in a rapid improvement in symptoms. It is used only to reduce symptoms of  flare-up and should not be continued orally in the long term.   Corticosteroids are associated with the development of peptic ulceration. Use  of corticosteroids in AX should be undertaken with caution and considered  only to treat aggressive flare-ups or until the condition is managed with  different disease-modifying antirheumatic agents. There are no interactions  reported when methylprednisolone is used in patients receiving fluvastatin and  no correlation with allergy to leflunomide.   Methylprednisolone is a steroid with a greater glucocorticoid activity  compared with prednisolone and lower mineralcorticoid effects. About 4 mg  of methylprednisolone are equivalent to the anti-inflammatory activity experi-  enced with 5 mg prednisolone. Methylprednisolone is similar to other corti-  costeroids and is rapidly absorbed from the gastrointestinal tract when  administered orally.   In addition to anti-inflammatory and immunosuppressive effects, glucocorticoid  activity results in metabolic effects including a decrease in peripheral glucose  utilisation and an increase in gluconeogenesis. This may lead to hyper-  glycaemia and increased insulin requirements in diabetic patients. When  measuring blood glucose, consideration has to be given to whether the  measurement was undertaken post-prandially or when the patient was fasting.   Cytokine inhibitors such as infliximab, etanercept, adalimumab are used as  disease-modifying antirheumatic drugs in the management of rheumatoid  arthritis. They may be considered to be additional treatment with methotrexate  if the frequency of flare-ups increases in AX.   Methotrexate is commonly prescribed as a weekly dose. Dispensing errors and  errors in drug administration, where the patient takes the drug on a daily basis  may occur. Patient should be counselled to ensure understanding of the dosage  regimen. Nausea and vomiting may occur with drug administration. Bone  marrow suppression is another side-effect of methotrexate. Patients should be    advised to report any signs of infection and a full blood count should be  performed every few months.   AX is prescribed folic acid to be taken weekly to prevent the stomatitis that  may occur as a result of methotrexate therapy. Folic acid is used to counter-  act the folate-antagonist action of methotrexate. Folic acid is reduced in the  body to tetrahydrofolate.    MB is complaining of palpitations, where the patient is aware of his or her's  heart beat, and this may present as a distressing phenomenon. Palpitations  may be signs of arrhythmias and tachycardia.   Moxonidine is a centrally acting drug that blocks imidazoline and alpha 2 -  adrenoceptors. It is used for the treatment of mild-to-moderate hypertension,  especially where the condition is unresponsive to first-line therapy.   Methyldopa and clonidine are two other antihypertensive drugs that are  centrally acting. Moxonidine is a newer drug that is associated with fewer  side-effects owing to its central action. Doxazosin blocks the alpha-adrenocep-  tors in the blood vessel walls and therefore brings about vasodilation. In hyper-  tension doxazosin and other alpha-adrenoceptor blocking drugs are used in  conjunction with other antihypertensives. Alpha-adrenoceptor blockers are  used as single therapy in the management of benign prostatic hyperplasia.    Hydralazine is a vasodilator that is used as an adjunct to other antihyper-  tensives in the management of moderate-to-severe hypertension.   Moxonidine is structurally similar to clonidine. As for clonidine, abrupt with-  drawal should be avoided as it may be associated with an increased cathecol-  amine release that may be manifested with agitation, sweating, tachycardia,  headache, nausea and rebound hypertension. MB may be presenting with  symptoms of palpitations caused by this effect as there are no other indica-  tions of symptoms related to heart failure and stroke. Bradycardia, severe  arrhythmias, severe heart failure, severe ischaemic heart disease and severe  renal or hepatic impairment should be excluded before moxonidine therapy  is started again.   Long-standing hypertension may cause complications associated with cardio-  vascular dysfunction, such as myocardial infarction, stroke and peripheral  vascular disease in the retina, kidneys and extremities. Hypertensive patients  should undergo tests to assess the presence or extent of end organ damage.  Tests include retinal examination, electrocardiogram, chest radiograph, kidney  function tests.    RB has systemic sclerosis, which is a type of scleroderma where there is chronic  hardening and thickening of the skin caused by collagen formation. Raynaud's  phenomenon is often a concomitant condition. Raynaud's phenomenon is  characterised by intermittent attacks of ischaemia in the extremities of the body  especially fingers and toes. On admission RB was taking pentoxifylline  (vasodilator) and nifedipine (calcium-channel blocker).   During an attack of Raynaud's disease, finger discoloration is common. Pain  is not usually a prominent symptom. RB is presenting with swelling, tenderness  and mild erythema. There is also a clear discharge beneath the nail fold which  may indicate infection. The management plan should include use of an anti-  bacterial agent to treat the infection that may have precipitated the symptoms.  Co-amoxiclav given as an intravenous therapy is an appropriate first choice  anti-bacterial agent as it is a broad spectrum agent. Co-amoxiclav consists of  clavulanic acid potentiated amoxicillin.   Pentoxifylline is a xanthine derivative that has vasodilating properties. It  increases blood flow to ischaemic tissues and results in an improvement of  tissue oxygenation in the affected areas. Side-effects of pentoxifylline include  gastrointestinal disturbances, dizziness, agitation, sleep disturbances and  headache. Hypotension may also occur and pentoxifylline should be used with  caution in patients with hypotension. Pentoxifylline may be used as long-term  therapy in the management of Raynaud's disease to reduce severe symptoms  and the frequency of acute attacks.   Factors that reduce blood flow in the fingers increase the risk of an acute  attack. RB should be advised to avoid exposure to cold temperatures and to  use lined gloves when handling food in freezers. She should use gloves in  winter to protect them from the cold. She should be advised to stop smoking  and information on smoking cessation should be provided. Emotional stress  and anxiety may also precipitate an attack.   Atenolol is a beta-adrenoceptor blocking drug. These drugs result in a reduced  peripheral circulation leading to coldness of extremities and may exacerbate  an acute attack of Raynaud's disease.   Nifedipine is a calcium-channel blocker which, unlike verapamil, has more  influence on the peripheral and coronary vessels than on the myocardium.  Nifedipine is a vasodilator that reduces the frequency and severity of  vasospastic effects in Raynaud's phenomenon. Its effect is better when started  early during the disease process. The use of a modified-release formulation  reduces variations in blood pressure and decreases reflex tachycardia. Patient  should be advised to swallow the tablet whole.    FG is admitted with symptoms of pulmonary oedema, chest infection and  angina. Her clinical laboratory tests, indicate hypokalaemia and leucocytosis.  She also has a high creatine kinase value which, together with the ST  depression and T wave flattening, indicate recent ischaemia. Cardiomegaly  is brought about by congestive heart failure. FG's blood glucose level is  extremely high. On admission FG's drug therapy consisted of paroxetine  (selective serotonin re-uptake inhibitor), potassium chloride supplement,  verapamil (calcium-channel blocker), dipyridamole (antiplatelet), bumetanide  (loop diuretic) and multivitamins.   On admission aims of treatment for FG are to control blood glucose levels, to  treat infection, to reduce pulmonary oedema and to provide prophylaxis  against ischaemic events. After an infarct, diabetic patients present with a high    blood glucose level as a result of a stress response by the body. Insulin is  required to reduce high blood glucose and patient should be maintained on  insulin therapy until stabilised. An assessment whether patient should continue  to receive antidiabetic treatment is required. High glucose levels, together with  the other disease states, increase FG's risk of ischaemic attacks which may be  associated with morbidity and mortality. Nitrates such as isosorbide dinitrate  are administered parenterally to prevent ischaemic attacks and to relieve  patient from the ischaemic pain. Nitrates are vasodilators. They bring about  an improvement in collateral blood flow in the heart and promote reperfusion,  thus limiting infarct size and preserve functional tissue. The use of aspirin after  an ischaemic event is associated with a lower risk of secondary thrombotic  cerebrovascular and cardiovascular disease.   FG has presented with hypokalaemia, which is corrected by increasing the  dose of potassium chloride supplements. Serum potassium levels should be  monitored. One of the complications of myocardial infarction is heart failure  and this is particularly relevant for FG, who already has a history of heart  failure. FG is presenting with symptoms of heart failure, and bumetanide  therapy may be switched to intravenous therapy for a few days until the  oedema is controlled. Verapamil is a calcium-channel blocker which slows  conduction in the atrioventricular node. Verapamil may cause worsening of  heart failure so it is recommended to stop verapamil therapy during this phase.   Oxygen therapy is started in the emergency department so as to provide  support to FG, who presents with shortness of breath. Oxygen is administered  with masks delivering 35% oxygen. As it is being administered intermittently  there is no need to use a nasal cannula; this is preferred when the patient is  going to require long-term administration of oxygen. Administering oxygen by  a nasal cannula decreases the interference caused by oxygen administration  on eating, drinking and talking because the mouth is not obstructed. An    oxygen concentration of 35% does not require humidification with a nebuliser  during administration.   Paroxetine is a selective serotonin reuptake inhibitor (SSRI). SSRIs together with  tricyclic antidepressants (TCAs) are used in the management of depression.  SSRIs and TCAs have similar efficacy but they differ in the side-effect profile.  The preference to use SSRIs is based on fewer antimuscarinic and cardiotoxic  side-effects. SSRIs may cause gastrointestinal effects, and side-effects include  movement disorders and dyskinesias. Paroxetine is a phenylpiperidine  derivative. Fluoxetine is another SSRI with similar properties to paroxetine.  Fluoxetine has a different chemical structure as it is a phenylpropylamine  derivative.   Dipyridamole is a phosphodiesterase inhibitor and an adenosine reuptake  inhibitor. It has antiplatelet and vasodilating properties. It is used for secondary  prevention of ischaemic stroke and transient ischaemic attacks. Its use in FG  should be monitored as dipyridamole should be used with caution in rapidly  worsening angina. Reports of transient myocardial ischaemia in patients with  unstable angina have been documented. Side-effects associated with the use  of dipyridamole include nausea, vomiting, diarrhoea, dizziness, myalgia,  throbbing headache, hypotension, hot flushes and tachycardia. Bleeding  disorders are not a common side-effect. Increased bleeding may occur during  or after surgery.   A chest radiograph reveals cardiomegaly in FG. Cardiomegaly or enlarge-  ment of the heart, usually caused by left ventricular hypertrophy, occurs to  accommodate the increased ventricular load. In heart failure, the ability of    cardiac muscle to respond to an increased preload through increased elastic  recoil is diminished. Sustained increased preload leads to loss of elastic recoil  possibilities. The increased ventricular load associated with cardiomegaly may  lead to pulmonary congestion. An increase in oxygen requirements of cardiac  cells leads to development of tachycardia, arrhythmias and myocardial  ischaemia.   Bumetanide may result in water and electrolyte imbalance, which may be  manifested by hypotension, muscle cramps, headache, dry mouth, thirst and  weakness. Dipyridamole may also cause hypotension. If the patient is started  on a nitrate, it also may cause hypotension. Blood pressure should be  monitored in FG, particularly during changes in drug therapy.   AP has a history of diabetes and cardiovascular disease. She presents with  chest pain and symptoms of unwellness. As she reports that pain started at  rest and is occurring from time to time, AP probably has unstable angina.  Stable angina is not associated with chest pain at rest. The ECG shows T wave  inversion, indicating recent infarction and this is confirmed from the elevated  creatine kinase level. On admission AP is taking candesartan (angiotensin-ll  receptor antagonist), clopidrogel (antiplatelet), isosorbide mononitrate  (nitrate), fluvastatin (statin), amlodipine (calcium-channel blocker), carvedilol  (beta-adrenoceptor blocker), bumetanide (loop diuretic), and isophane insulin  (intermediate-acting insulin).   Carvedilol is a non-cardioselective beta-adrenoceptor blocker. It blocks the  beta-receptors of the sympathetic nervous system in the heart, peripheral vascu-  lature, bronchi, pancreas and liver. A characteristic of carvedilol is that it also    has vasodilating properties and it is used in the management of heart failure,  where it has been shown to decrease mortality. Unlike atenolol, carvedilol has  high lipid solubility.   Hypotension may occur as a common side-effect of a number of drugs that  are included in AP's treatment. Isosorbide mononitrate is a vasodilator that  presents postural hypotension as a common side-effect. Carvedilol, which also  has vasodilating properties, may also cause postural hypotension. Amlodip-  ine and candesartan too may cause hypotension, and the risk is higher in  patients who are taking diuretics and may develop dehydration. Amlodipine  commonly induces flushing especially at the start of therapy and isosorbide  mononitrate may also cause flushing.   Candesartan is an ester prodrug and it is hydrolysed to the active form during  absorption from the gastrointestinal tract. It is an angiotensin-ll receptor  antagonist that blocks the angiotensin receptors, resulting in a decreased effect  of angiotensin II. Angiotensin-ll receptor antagonists have similar properties to  angiotensin-converting enzyme (ACE) inhibitors. Both classes of drugs are used  in the management of hypertension and heart failure. An important feature of  angiotensin-ll receptor antagonists is that, unlike ACE inhibitors, they do not  inhibit the breakdown of bradykinin. This activity, which occurs with ACE  inhibitors, is associated with cough as a side-effect of ACE inhibitors. Cough  does not usually occur with candesartan and other angiotensin-ll receptor  antagonists and in fact they may be used in patients who are intolerant to ACE  inhibitors owing to this side-effect. It has a long elimination halflife (about 9 h)  and is usually given as a once-daily dose. Angiotensin-ll receptor antagonists  should be used with caution in renal artery stenosis as they may reduce  glomerular filtration rate precipitating renal failure.   Isophane insulin is an intermediate-acting insulin preparation that allows twice-  daily injection. AP should be advised to avoid episodes of hypoglycaemia by  correctly following the dose administration of insulin and keeping a standard  food intake pattern. The risk of hypoglycaemia is highest before meals and  at night. A response to hypoglycaemia is the activation of the sympathetic  nervous system and adrenal medulla. This response leads to tremor, pallor,  sweating, shivering, palpitations and anxiety, which are early clinical signs of  hypoglycaemia. Such a response increases oxygen demand in the cardiac  muscle and may precipitate angina attacks and myocardial infarction in AP.  During an anginal attack, glycaemic control is lost because of the resulting  metabolic stress and insulin requirements are increased.   Isosorbide mononitrate is a nitrate that is used in angina. Nitrates are potent  coronary vasodilators and bring about a reduced venous return. It has an  elimination halflife of 4-5 h. Modified-release formulations are available  where dosage regimen is once daily. The advantages of a modified-release  formulation is that major peaks and troughs in drug blood levels are avoided  and this results in better control of anginal symptoms. Once-daily dosing of  the modified-release formulation results in low blood-nitrate concentrations  towards the end of the 24-h period, and this avoids the development of the  tolerance associated with nitrates. Isosorbide mononitrate is metabolised to  inactive metabolites such as isosorbide and isosorbide glucuronide.   Fluvastatin is a statin that acts as a 3-hydroxyl-3-methylglutaryl coenzyme A  (HMG CoA) reductase inhibitor. Statins are used as lipid regulating drugs and  they reduce low-density-lipoprotein cholesterol (LDL cholesterol). AP should be  advised to report muscle pain immediately as statins may cause myalgia and  muscle weakness, which may be associated with myopathy, which may    progress to rhabdomyolysis and renal failure. Occurrence of myopathy and  rhabdomyolysis is associated with an elevated creatine kinase. Statins should  be used with caution in patients with a history of liver disease and are not  indicated during active liver disease. Liver function tests are required before  starting statin therapy. Statins should be used with caution in severe renal  impairment. Renal function tests should be carried out at baseline. AP was  taking fluvastatin 80 mg at night, which is the maximum recommended dose.  Hypothyroidism should be corrected before starting statins as correction may  resolve the hyperlipidaemia. Thyroid function tests should be carried out,  especially in elderly patients who may have a hypothyroid state with sub-  clinical symptoms. Simvastatin is another statin that may be used as an alterna-  tive and the maximum therapeutic dose is 80 mg daily.   Unstable angina may present with negative outcomes and requires immediate  hospitalisation. Complete bed rest is recommended for a few days. AP should  be started on oxygen, isosorbide mononitrate is changed to a nitrate intra-  venous infusion, such as isosorbide dinitrate injections. AP is already on  clopidrogel which is an expensive antiplatelet drug. Clopidrogel is used in the  management of unstable angina. Heparin or the low-molecular-weight  (LMWH) heparins may be used for the first 2-5 days. Use of heparin products  with clopidrogel increases risk of bleeding.    KB presents with symptoms associated with disorders of the urinary tract. She  is complaining of dysuria (painful urination) that occurs as a result of infection  or obstruction in the urinary tract. KB also presents with urinary urgency and  urinary frequency.   The symptoms presented by KB are suggestive of a lower urinary tract infection  also known as cystitis, where the bladder and urethra are involved. Bacteria  may ascend the urinary tract to affect the kidneys leading to acute pyelonephri-  tis. A common causative organism of cystitis and acute pyelonephritis is  Escherichia coli. Vulvovaginitis is an inflammation of the vulva and vagina,  which is not associated with urinary urgency and urinary frequency.   Patient should be asked about occurrence of fever. This helps to differentiate  between cystitis and acute pyelonephritis. The latter is associated with fever,  chills, pain in the sides and nausea, in addition to the urinary symptoms.  Pharmacists can carry out a urinalysis to confirm diagnosis. Bacterial urinary  tract infection leads to an alkaline urine pH as a number of organisms,  including E. coli, are urea-splitting organisms. Haematuria and the presence  of nitrites in urine caused by bacterial enzymes that reduce urinary nitrates to  nitrites also occur. The test may be repeated after the recommended treatment  has been completed so as to confirm that bacterial infection has been eradi-  cated. Culturing of bacteria present in urine from mid-stream samples may be  required to identify causative organism, to use anti-bacterial agents that are  active against the particular microorganism. However, in the normal setting,  when the patient is presenting with primary symptoms and there are no other  complications, this test may be delayed.   KB is advised to drink lots of water to flush out the urinary system and dilute  the microorganisms. Alkalinisation of urine may be used to relieve the discom-  fort caused by the urinary tract infection. Potassium citrate salts are used. If  KB has signs of acute pyelonephritis or symptoms have not subsided with  potassium citrate salts, then antibacterial agents are required.   Antibacterial agents that are active against E. coli are recommended for the  management of cystitis and acute pyelonephritis. Drugs used include broad-  spectrum penicillins such as amoxicillin and co-amoxiclav, broad-spectrum  cephalosporins such as cefalexin and cefuroxime, trimethoprim and quino-  lones such as ciprofloxacin.    SC is presenting with high blood pressure during the first month of pregnancy.  Increased blood pressure during pregnancy may be associated with pre-  eclampsia and intrauterine growth retardation.   As there is hypertension before the first 20-24 weeks of pregnancy, there is  a probability that hypertension was pre-existing before conception. SC has a  higher risk of developing pre-eclampsia. Pre-eclampsia presents with hyper-  tension, proteinuria and oedema. Complications of pre-eclampsia include  early delivery, low-birth-weight and eclampsia, which can result in maternal  and fetal death. Eclampsia is associated with seizures and coma. Hyper-  tension may be due to secondary causes. However, this cannot be deduced  from the clinical presentation.   During pregnancy, SC should be monitored to assess the development of the  symptoms of pre-eclampsia, namely hypertension, proteinuria and changes in  fetal growth. During check-ups SC should have her blood pressure measured  and urinalysis routinely carried out. Fetal growth should be regularly  monitored.   During pregnancy, the use of thiazide diuretics, beta-adrenoceptor blockers,  angiotensin-converting enzyme (ACE) inhibitors and angiotensin-ll receptor  inhibitors should be avoided. Thiazide diuretics may cause neonatal thrombo-  cytopenia. ACE inhibitors and angiotensin-ll receptor inhibitors may affect  maternal renal function and lead to intrauterine death. Beta-blockers may  cause intrauterine growth retardation. They may be used after the third  trimester if other drugs are not effective or are contraindicated.   Methyldopa, a centrally acting antihypertensive agent, may be used in  pregnancy. It has a very good safety record when used for the management  of hypertension in pregnancy. Hydralazine, a vasodilator, may be used after  the third trimester.   Labetalol is a non-cardioselective drug that acts as a competitive antagonist  to alpha and beta-receptors in the sympathetic nervous system. Owing to its  action on the alpha receptors, it results in vasodilation leading to a lower  peripheral resistance. The chemical structure of labetalol has two optical  centres and formulations available clinically may present a mixture of the four  diasteriomers.    HG is presenting with symptoms of allergic rhinitis. Allergy results from an  inappropriate immune response by the body to an allergen. HG states that  she has been using oxymetazoline spray, which is a direct-acting sympatho-  mimetic agent that is used as a nasal decongestant.   HG may have the perennial type of allergic rhinitis as she states that she has  recurrent attacks of nasal allergy indicating that the attacks may not be  seasonal. Allergens include house dust, pollen and pet fur. Exposure to the  allergen(s) results in mast cells and T lymphocyte activation that lead to the  release of histamine, leukotrienes, prostaglandins and kinins. Symptoms of  allergic rhinitis include nasal itching, rhinorrhoea, itchy throat, sneezing and  dry cough, particularly at night. Conjunctival symptoms may also occur.   In HG, oxymetazoline provides relief against nasal congestion. Oxymetazo-  line is an alpha-adrenoceptor agonist and its topical administration causes  nasal vasoconstriction, thus reducing swelling and congestion in the nasal  mucous membranes. However, prolonged use may lead to rebound conges-  tion, also known as rhinitis medicamentosa. Patients should be advised not to  use it for more than 1 week. HG should be advised to stop using oxymetazo-  line. Oxymetazoline is available for topical nasal application as nasal spray  or nasal drops.   Desloratidine is an antihistamine that may be used for symptomatic relief in  HG. The product may be used on a long-term basis and the non-sedating  property of desloratidine is an advantage with regards to the lower incidence  of sedation compared with older sedating agents. Desloratidine is an active  metabolite of loratidine and it is available for oral administration on a once-  daily regimen. Antihistamines reduce secretions, nasal itching, sneezing and  ocular symptoms and are considered to be a first-line option in the manage-  ment of mild or intermittent allergic rhinitis.   Budesonide is a corticosteroid that was developed for inhalation for the  management of asthma. It is also available as a nasal spray for use in allergic  rhinitis and as an oral formulation that is used in the management of Crohn's  disease. Corticosteroids are used in the treatment and prophylaxis of allergic  rhinitis and asthma. Corticosteroids decrease production of cytokines and  chemokines associated with the inflammatory reaction brought about after  exposure to allergens.   HG should be advised to avoid exposure to allergens. She should be advised  to avoid walking in gardens and to use products to eradicate house dust mites  regularly in the house. Blood in sputum (haemoptysis) is not associated with  allergies or asthma but may indicate conditions such as lung cancer or  infectious diseases, for example, tuberculosis. Its occurrence requires referral  for assessment.    Armour D, Cairns C (2002). Medicines in the Elderly, London: Pharma-  ceutical Press.   Boh L E, Young L Y (2001). Pharmacy Practice Manual: a guide to the  clinical experience, 2nd edn. Maryland: Lippincott Williams &  Wilkins.   Brunton L L, Lazo S J, Parker K L, eds (2006). Goodman & Gilman’s  The Pharmacological Basis of Therapeutics, 11th edn. New York:  McGraw-Hill.   Como D N (1998). Mosby’s Medical, Nursing and Allied Health Diction-  ary, 5th edn. St Louis, Missouri: Mosby.   Grahame-Smith D G, Aronson J K (1995). Oxford Textbook of Clinical  Pharmacology and Drug Therapy, 2nd ed. Oxford: Oxford University  Press.   Greene R J, Harris N D (2000). Pathology and Therapeutics for Pharma-  cists: a basis for clinical pharmacy practice, 2nd edn. London: Pharma-  ceutical Press.   Mehta D K, ed. (2007). British National Formulary, 53rd edn. London:  Pharmaceutical Press.   Pagana K D, Pagana T J (1998). Mosby’s Manual of Diagnostic and  Laboratory Tests, St Louis, Missouri: Mosby.   Patel A (2003). Diabetes in Focus, 2nd edn. London: Pharmaceutical  Press.   Randall M D, Neil K E (2004). Disease Management, London: Pharma-  ceutical Press.   Sweetman S C, ed. (2007). Martindale: the complete drug reference, 35th  edn. London: Pharmaceutical Press.   Tietze K J (2004). Clinical Skills for Pharmacists: a patient-focused  approach, 2nd edn. Missouri: Mosby.   Walker R, Edwards C (2003). Clinical Pharmacy and Therapeutics, 3rd  edn. Edinburgh: Churchill Livingstone.    Acne: skin condition occurring in areas where sebaceous glands are  numerous presenting with comedones, papules, and pustules  Adenoma: a tumour of glandular epithelium where the cells are  arranged in a characteristic glandular structure  Agranulocytosis: reduction in the number of white blood cells  Akathisia: restlessness and inability to sit still  Allergic rhinitis: a condition where nasal passages are inflamed and  watery nasal discharge occurs   Anaemia: a condition where haemoglobin in blood is decreased  Anaphylaxis: hypersensitivity reaction to a previously encountered  antigen that may be life-threatening  Angina: occurrence of thoracic pain associated with myocardial  anoxia   Anovulatory infertility: infertility caused by failure of ovaries to  produce mature ova or to release ova  Arrhythmia: deviation from normal heart beat pattern  Asthma: a respiratory condition characterised by dyspnoea and  wheezing caused by bronchoconstriction and viscous bronchial  secretions   Atherosclerosis: plaques consisting of cholesterol, lipids and  cellular debris in the inner layers of the walls of arteries  Atopic eczema: a skin condition that is associated with intense  pruritus and inflammation   Atrial fibrillation: cardiac arrhythmias caused by disorganized  electrical activity in the atria   Biliary colic: pain caused by stones passing through bile ducts  Bradycardia: a decreased heart rate  Bradykinesia: general slowness of movement  Breath sounds: detection using a stethoscope of the sound of air  going through the airways into the lungs  Candidiasis: infection caused by Candida species    Cardiac arrest: cessation of cardiac output  Cardiomegaly: enlargement of the heart   Cardiomyopathy: a condition that interferes with the structure and  function of the heart   Cataract: loss of transparency of the lens of the eye  Cellulitis: an acute infection of the skin and subcutaneous tissue  Cerebrovascular accident: occlusion by an embolus in the brain or  cerebrovascular haemorrhage  Cholangitis: inflammation of the bile ducts  Cholecystitis: inflammation of the gall bladder  Chronic myelocytic leukaemia: malignant neoplasia of blood-  forming tissues characterised by proliferation of granular  leukocytes   Chronic obstructive pulmonary disease: a respiratory condition  where inspiratory and expiratory capacity of the lungs are  decreased   Cirrhosis: chronic degenerative disease of the liver  Colonoscopy: diagnostic procedure to examine the colon and  terminal ileum   Congestive heart failure: a condition associated with impaired  pumping action of the heart   Crossmatching of blood: matching compatibility of a donor’s  blood with that of the recipient   Cushing’s disease: a disorder where there is an increased secretion  of adrenocortical steroids   Cyanosis: bluish discoloration of the skin usually in the peripheries  Cystitis: lower urinary tract infection  Deep vein thrombosis: occurrence of a thrombus in a vein  Depression: a mood disturbance disorder characterised by sadness,  despair and discouragement   Diabetes: a metabolic disorder associated with a deficiency or  complete lack of insulin secretion or with defects in insulin  receptors   Diabetic ketoacidosis: acidosis caused by accumulation of ketones  in the body resulting from extensive breakdown of fat  Diaphoresis: sweating    Dysentry: a condition caused by inflammation of the intestine  caused by microorganisms or chemical irritants  Dyskinesia: impaired voluntary movement  Dysphagia: difficulty in swallowing  Dysphasia: impairment of the language aspect of speech  Dyspnoea: uncomfortable breathing   Dysuria: painful urination that occurs as a result of infection or  obstruction in the urinary tract   Eclampsia: pregnancy-induced hypertension characterised by  grand mal seizures, proteinuria and oedema  Encephalopathy: abnormality in the structure or function of the  brain   Erythema: redness of the skin or mucous membrane caused by  dilation and congestion of superficial capillaries  Finger clubbing: enlargement of the distal phalanges of digits, most  commonly of the fingers   Gastritis: a condition where there is inflammation of the lining of  the stomach   Gastro-oesophageal reflux disease: a condition characterised by  regurgitation of stomach contents into the oesophagus, usually  caused by an incompetent lower oesophageal sphincter  Gastroscopy: visual inspection of the stomach using a gastroscope  Glaucoma: raised intraocular pressure   Gout: a condition associated with either an increased production  of uric acid or a decreased excretion of uric acid  Haematemesis: vomiting of red blood indicating bleeding in the  upper gastrointestinal tract   Haemophilia: condition where there is a deficiency of one of the  factors required for blood coagulation  Haemoptysis: blood in sputum  Heart attack: see Myocardial infarction  Heart failure: see Congestive heart failure    Hypercalcaemia: elevated serum calcium level  Hypercholesterolaemia: increased cholesterol levels in blood  Hyperglycaemia: increased glucose level in blood  Hyperkalaemia: increased serum potassium level  Hyperlipidaemia: increased lipids in blood  Hypernatraemia: increased serum sodium level  Hyperparathyroidism: hyperactivity of the parathyroid glands  resulting in excessive secretion of parathyroid hormone  Hyperplasia: an increased number of cells caused by an increased  rate of cellular division   Hyperpyrexia: an extremely high body temperature  Hypersensitivity: an abnormal response of the immune system to  an antigen   Hypertension: elevated blood pressure  Hyperuricaemia: an increased uric acid blood level  Hypervolaemia: increase in the intravascular fluid  Hypocalcaemia: a decreased serum calcium level  Hypochromic anaemia: a type of anaemia where there is a  decreased concentration of haemoglobin in the red blood cells  Hypoglycaemia: a decreased blood glucose level  Hypokalaemia: decreased serum potassium level  Hypomagnesaemia: decreased serum magnesium level  Hypomania: a mild form of mania that is characterised by  optimism   Hyponatraemia: decreased serum sodium level  Hypoprothrombinaemia: abnormally decreased amount of  prothrombin in the blood  Hypotension: low blood pressure   Hypothyroidism: decreased activity of the thyroid gland  Hypoxia: inadequate oxygen supply to cells  Idiopathic thrombocytopenia purpura: a decreased amount of  platelets leading to bleeding in the skin and organs  Ileus: obstruction of the intestines    Infectious mononucleosis: a viral infection caused by the Epstein  Barr virus that is characterised by fever, sore throat, swollen  lymph glands, splenomegaly, and hepatomegaly  Iron deficiency anaemia: anaemia caused by supplies of iron not  meeting the demand for the synthesis of haemoglobin  Irritable bowel syndrome: a condition that results in increased  motility in the small and large intestines  Ischaemic heart disease: a condition that occurs in the myocardium  as a result of decreased oxygen supply to myocardial tissues  Jaundice: a condition where there are increased amounts of  bilirubin in the blood leading to a yellowish discoloration of the  skin, mucous membranes and the eyes  Left ventricular heart failure: heart failure where the left ventricle  is not contracting forcefully resulting in a depressed cardiac  output and compromised peripheral perfusion  Leucoctyosis: an increase in white blood cells in the blood  Leucopenia: a decrease in white blood cells in the blood  Macroangiopathy: enlarged blood vessels   Megaloblastic anaemia: anaemia characterised by large immature  dysfunctional red blood cells   Melaena: stools that contain digested blood indicating bleeding in  the upper gastrointestinal tract  Metabolic acidosis: blood pH less than 7.1  Metatarsalgia: pain around the metatarsal bones  Microalbuminuria: the excretion of albumin in urine in small  amounts   Mitral stenosis: obstruction in the mitral valve which is found  between the left atrium and the left ventricle in the heart  Mumps: a viral infection caused by paramyxovirus that is charac-  terised by a swelling of the parotid glands  Muscular dystrophy: a progressive inherited condition that results  in atrophy of symmetric groups of skeletal muscle  Myalgia: muscle pain    Myocardial infarction: damage to sections of cardiac muscle  characterised by severe crushing chest pain  Myopathy: muscle weakness and wasting  Myopia: elongation of the eyeball leading to shortsightedness  Myositis: inflammation of muscle tissue  Necrosis: tissue death as a result of disease or injury  Neuralgia: occurs with conditions affecting the nervous system and  presents with severe pain   Nosocomial infection: hospital-acquired infection  Oedema: accumulation of fluid in interstitial body cavities  Oesophagitis: inflammation of the oesophagus  Optic fundus: base of the interior of the eye  Orthopnoea: uncomfortable breathing; the patient needs to change  posture to a particular position to breathe comfortably  Osteoarthritis: a form of arthritis where involved joints undergo  degenerative changes   Osteomyelitis: infection of bone and bone marrow  Osteoporosis: a condition affecting the bone structure caused by  loss of bone density   Otitis media: a condition of the middle ear caused by inflamma-  tion or infection   Paget’s disease: condition associated with excessive bone destruc-  tion and abnormalities in bone repair  Pancreatitis: inflammation of the pancreas   Parkinson’s disease: a degenerative neurological condition that is  characterised initially by tremor at rest, pill rolling of the fingers  and a shuffling gait   Petechiae: red spots on the skin as a result of small haemorrhages  in the dermal or submucosal layers  Phaeochromocytoma: tumour of the chromaffin tissue of the  adrenal medulla or sympathetic paraganglia  Polyuria: large quantity of urine production    Pre-eclampsia: condition during pregnancy characterised by acute  hypertension after the 24th week of gestation  Prickly heat: a condition mostly caused by exposure to heat and  high humidity resulting in small vesicles and papules, and  erythema   Pulmonary congestion: accumulation of fluid in the lungs caused  by cardiovascular disease or inflammation  Pulmonary infarction: thrombus-caused obstruction in a pulmon-  ary artery   Pulmonary oedema: accumulation of fluid in lung tissues and alveoli  Pulmonary stenosis: cardiac condition associated with hypertrophy  of the right ventricle   Purpura: bleeding disorders causing haemorrhage into tissues  Pyelonephritis: infection of the kidney   Raynaud’s phenomenon: a condition characterised by ischaemia of  the extremities of the body, particularly the fingers  Renal artery stenosis: obstruction of the renal artery  Renal infarction: necrosis in the kidneys resulting from tissue  anoxia   Retinopathy: changes in the blood vessels in the retina  Rhabdomyolysis: a condition of the skeletal muscle characterised  by myoglobulinuria that may be potentially fatal  Reye’s syndrome: a condition characterised by acute encephalopa-  thy and fatty degeneration of the liver  Rheumatoid arthritis: chronic inflammatory condition charac-  terised by symmetric inflammation of synovial joints  Rheumatoid factor: antibodies that are present in the serum of  patients with rheumatoid arthritis  Sclerosis: hardening of tissues   Shingles: herpes zoster infection that presents with a unilateral rash  and pain   Sjogren’s syndrome: a condition that has an immunological  component and is characterised by dryness of the eyes, mouth  and mucous membranes    Sleep apnoea: periods during sleep of cessation of breathing of at  least 10 s   Splenomegaly: enlargement of the spleen  Stomatitis: inflammation of the mouth  Stroke: cerebrovascular accident   Subdural haematoma: accumulation of blood in the subdural area  Synovitis: inflammation of the synovial membrane of a joint  Tachycardia: rapid heart rate  Tachypnoea: abnormally fast breathing rate  Tardive dyskinesia: involuntary repetitive movements of muscles  in the face, limbs and trunk   Thalassaemia: a condition caused by hemolytic anaemia that  occurs as a result of deficient haemoglobin synthesis  Thrombocytopenia: reduced number of platelets  Thromboembolism: blockage of a blood vessel by an embolus that  is carried in the blood stream  Tinnitus: a sensation of hearing ringing sounds  Transient ischaemic attack: short episodes of cerebrovascular  insufficiency caused by partial occlusion of an artery or  embolism   Trigeminal neuralgia: a neurologic condition affecting the trigem-  inal nerve, characterised by stabbing pain occurring along the  facial trigeminal nerve   Unstable angina: sudden occurrence of angina that worsens  suddenly and may progress to acute myocardial infarction  Urinalysis: examination of the urine  Vulvovaginitis: inflammation of the vulva and vagina  Wilson’s disease: an inherited disorder associated with a decrease  in ceruloplasmin, which causes copper to accumulate slowly in  the liver, and which is then released into the circulation and  taken up by other tissues    accident and emergency  angiotensin-converting enzyme  alkaline phosphatase  alanine aminotransferase  aspartate aminotransferase  twice daily  blood pressure  beats per minute  blood urea nitrogen  complete blood count  congestive heart failure  creatine kinase    Normal ranges for laboratory tests vary significantly depending on the method of testing and the  laboratory. The values reported here are for the adult population and are indicative of normal  values.    Alanine aminotransferase  Alkaline phosphatase  Aspartate aminotransferase  Bilirubin, total, blood  Blood glucose, fasting  Blood glucose, random  Blood pressure  BUN   3.6- 7. 1 mmol/l  96-1 06 mmol/l  <5.20 mmol/l  <175 U/l  50-1 10 pmol/l  < 30 mm/hr  8-38 U/l   >0.75 mmol/l  <3.37 mmol/l  80-95 mm 3  27-31 pg  32-36 g/dl  7.1   3. 5- 5.0 mmol/l  60-80 beats/minute  4. 4-5. 8 X 10'7I   1 35-1 45 mmol/l  4-1 2 pg/ dl  0.8-2. 7 ng/dl    37°C (98.6°F)  2-10 mU/l  0.40-1 .52 mmol/l  3. 0-8.0 mmol/l  0.15-0.48 mmol/l  5-10.0 X 10 9 /l    Tests 1 to 4 were undertaken by a sample of final-year pharmacy  students following a five-year undergraduate course. The percent-  age of students answering a question incorrectly is indicated for  each test. For each test, the median score obtained by the student  group is presented.   Where there are two numbers in parens, the first one refers to the preamble to the  question.    acarbose, gliclazide with, 100 (68)  acetazolamide, 101-3 (69-70)  aciclovir, 46^17 (17-18), 169 (140)  adalimumab, 206  adrenaline, 33-4 (4), 144 (115)  alendronic acid, 167  allopurinol, 52 (24)  alteplase, 200 (175)  aluminium salts, 196 (173)  aminophylline, 153-4 (120-1, 123)  amiodarone, phototoxicity, 196 (173)  amitriptyline, 108-10 (77, 78-9)  herpes zoster, 47 (17, 18)  movement disorder, 98-9 (66), 111  (77, 80)   and QT interval, 202 (177)  postherpetic neuralgia, 170 (139, 141)  amlodipine, 213-214 (186, 187)  amoxicillin 37, (123), 218, see also  co-amoxiclav   aspirin, (25), 93 (60), 104 (71, 72), 108,  114 (81, 83), 135 (163), 149  (119)    ischaemic heart disease, 158, 159  (127, 129-30), 211 (184, 185)  stroke, 198 (174)   atenolol, (12, 13), 49 (21), 53 (25), 95,  96 (60-1, 62, 64), 152 (120-1,  122), 210 (182, 183), 213-14  (186, 187)   126), 156 (120-1, 126)  bendroflumethiazide, 49, 50 (21), 201,  203-4 (177)   benzylpenicillin, 47-8 (19)  bisacodyl, 101 (69)  bisoprolol, 95 (60-1, 62)  budesonide, 109 (78), 155-6 (120-1,  126), 221 (190, 191)  bumetanide, 39 (6, 8), 94 (60-1, 62), 97  (60-1, 64), 108-9 (77, 78), 211  (184, 185), 213 (184, 186)   calcium supplements, 163 (135), 164-65,  167 (136), 199 (175)  candesartan, 146 (117), 214 (186, 187),  219 (190)    capecitabine, 198 (174)  carbamazepine, 170 (139, 141)  carvedilol, 95 (60-1, 62), 213-14 (186,  187)   cefuroxime, 98 (65), 103 (70, 71), 106  (73, 74), 151, 154 (120-1, 123),  218 (188, 189)  chlorphenamine, 12  ciclosporin, 146 (117), 201 (176)  cinnarizine, 147 (118)  ciprofloxacin, 40-1 (8, 10), 103 (70, 71),  218   citrate (of potassium), 217 (188)  clarithromycin, 37 (6), 151, 154 (120-1,  124), 173   clavulanic acid see co-amoxiclav  clonidine, 207-8 (181, 182)  clopidrogel, 213, 216 (186, 188)  clozapine, 145 (117)  co-amoxiclav, (8), 103 (70, 71), 109 (77,  78), 208-9 (182, 183), 218 (188,  189)   co-codamol, 99-100 (67), 104 (71, 72),  113-14 (81, 82-3), see also  codeine   co-magaldrox, 196 (173)  cod liver oil, 163 (135)  codeine, 99-100 (67), 104 (71, 72),  113-114, (183) see also co-  codamol   darbepoietin, 201 (176)  desloratadine, 220 (190, 191)  dexamethasone, 147 (118)  dextrose, rehydration, 109 (77, 78)   digoxin, 46 (15, 16-17), 108 (77), (132),  144-5 (115, 116), 202-3 (177,  178)   dimenhydrinate, 147 (118)  dipyridamole, 35 (5), 44-5 (13-14), 53  (25), 99, 101 (67), 105 (73), 162  (133), 210-13 (184, 185-86)  disodium pamidronate, 165, 167 (136,  138)   docusate sodium, 102 (69)  domperidone, 104 (71, 72)  dorzolamide, 102-3 (69, 70)  doxazosin, 207-8 (181, 182)  doxorubicin, (181), 200   (60-1, 63-4), 157, 159 (127, 130)  enoxaparin, 35 (5)  ergotamine, 18   erythropoietin, 201 (176)  esomeprazole, 107 (76)  etanercept, 167-8 (136, 139), 206 (179,  181)   famciclovir, 169 (139, 140-1)  fentanyl, transdermal patches, 145 (116)  ferrous sulphate, 99-100 (67), 108 (76),  151 (120)   filgrastim, 147 (118)  flucloxacillin, 98 (65), (189)  fluconazole, 98 (65)  fluoxetine, 202 (177), 212 (184, 185)   folic acid, methotrexate with, 166 (136,  138), 204, 207 (179, 181)  framycetin, 101, 102 (69, 70)  furosemide, 157, 160 (127, 131), (190)  fusidic acid, (8, 10), 112, see also  sodium fusidate   gabapentin, 170 (139, 141)  gentamicin, 48 (19, 20), 103 (70, 71)  glibenclamide, 40-42 (8, 10-11), 105  (73-4), 163-4 (135)  gliclazide, 41 (8, 10), 99, 100 (67, 68),  107 (76), 163-64, (173)  glimepiride, 53 (25)  glipizide, 164   haloperidol, 40-2 (8, 9-10)  heparin, 35 (5), 158, 159, 160 (127,  129-31), 216 (186, 188)  human immunoglobulins, 197 (174)  hydralazine, 208 (181, 182), 219  hydrocortisone, 112 (80, 81), 151,   ibuprofen, 104 (71, 72), 113-4 (82), 170  (139, 141), (188)  imipramine, (66), 110 (77, 79)  indometacin, 51 (21, 23)  infliximab, 167-8 (136, 139), 206 (179,  181)   insulin, (74), 106, 149 (119), 210-11  (184, 185), 213, 215 (186, 187)    antibodies vs, 194 (171, 172)  interferon alfa, 197-8 (174)  ipatropium, 153-4 (123)  irinotecan, 198   isophane insulin, 213, 215 (186, 187)  isosorbide dinitrate, 33 (4), 94 (62), 97  (60-1, 64), 99, 100, 101(67),  157-9 (127, 129-130), 164 (136),  211 (185), (187), 216  isosorbide mononitrate, 94, 163, 164  (135, 136), 213-5 (186, 187)  isotretinoin, 36 (5)   labetalol, 219 (189, 190)  lactulose, 44, 45 (13, 14), 101-3 (69,  70-1)   latanoprost, 102-103  leflunomide, 179, 205  lenograstim, 147  levothyroxine, 53 (25)  liquid paraffin, 69, 101-2  lithium, 12, 202 (177)  loratadine, 93   magnesium salts, 36, (69), 102, 196  mepyramine, 112 (80, 81)  metformin, 53 (25), 100, 108-10 (77,  79), 157, 159, 160 (127, 130-31)  methadone, 34 (4)   methotrexate, 165-167 (136, 137-8),  204, 206-7 (179, 181)  methylcellulose, 25  methyldopa, 207-8 (181, 182), 219  (189, 190)   metolazone, 39 (6, 7-8)  metoprolol, 95 (60-1)  metronidazole, 37 (6), 106 (73-4)  miconazole, 112 (80, 81)  morphine, 106-7 (75)  moxonidine, 207-8 (181-2)   nabilone, 150  nalidixic acid, 98 (65)  nifedipine, 161, 162-63 (133, 134), 208,  210 (182, 183)  noradrenaline, 99, 144 (115)  normal saline, 92 (59), 109 (77, 78)   pegfilgrastim, 147  peginterferon alfa, 197-8 (174)  penciclovir, 169 (139, 140)  penicillin G, 48 (19, 20)  penicillin V, (19)   pentoxifylline, 208, 209 (182, 183)  perindopril, (77), 108, 163, 164 (135),  202, 203^1 (177, 178)  phenytoin, 200 (175)  phytomenadione, 35 (5)  piperacillin, (19)  pivmecillinam, (19)    potassium chloride, 93, 94, 96 (60-61),  144-5, 201 (177), 204 (178),  210-11 (184, 185)  potassium citrate, 217 (188)  prednisolone, 31 (3), (78), 154, 155  (120-1, 124, 125), 165-7 (136)  kidney transplantation, 201 (176)  methotrexate and, 166 (136, 138)  methylprednisolone vs, 205, 206 (179,  180)   peptic ulcer, 155 (120-1, 125), 166  (136, 137-8)  probenecid, 52-3 (21)  prochlorperazine, 147  promethazine, 42 (11, 12), (183)  propranolol, 31 (3)   salmeterol, 156 (120-1, 126)  senna, 101-102 (69)  simvastatin, 53 (25), 43-4 (12-13), 160  (127, 131-2), 216 (186, 188)  sodium bicarbonate, parenteral, 34-5 (4)  sodium chloride, 35, 40, 41 (8, 10), 92  (59), 109   sodium fusidate, 103 (70, 71)  spironolactone, 45-6 (15-17)  sulfinpyrazone, 52-3 (21)    teicoplanin, 148  telithromycin, 37 (6)  theophylline, 153  thyroxine, 53-54 (25-6)  timolol, 44-5 (13-14), 101-3 (69, 70),  152 (120-1, 122)  tramadol, 104 (71, 72)  trimethoprim, 218   vitamin D, 167 (136), 199 (175)  vitamin K, 35 (5), 145 (117)   warfarin, 145 (117), 149 (119)  atrial fibrillation, 204 (177, 178)  INR, 86 (56)   acid regurgitation, 196 (173)  acidosis, metabolic, 34-35 (4)  acne, 36, 143  addiction, opioids, 34 (4)  adenocarcinoma, 146, 194  agitation, 208, 209  agranulocytosis, (66), 145  akathisia, (66)  alcoholism, 42-43 (11-2)  alkalosis, 91   allergies, (20), 29, 97-8 (65-6), 103,  151-2 (120-1)  alopecia, 90, 147 (118)  anaemia, 29 (1), 107-108 (76-7), 143,  166 (137), 201 (176), 204-5  (181)   anaphylaxis, 33-4, 91 (59), (124)  angina, 33, 54 (27), 89 (58), 94 (62),  156-7 (127, 128), 162, 164,  194-5, 210-3 (184, 185-6),  213-6 (186-8) see also  cardiovascular disease; ischaemic  heart disease   anorexia, 46, 49, 109, 144-145  anovulatory infertility, 34  anxiety, 89 (58), 112-114 (81-3)  aortic stenosis, 162  aphasia, 31 (2)  appendicitis, 58   203, 207-8 (181-2) 212-3 see  also atrial fibrillation  asthma, 36-7 (5), 92-93 (60), 114,   151-156 (120-7), 201-204 (177,  178), 221 (190, 191)  ataxia, 95 (63)   atherosclerosis, 88 (57), 100-101, 157  atonic colon, 101 (69)  atopic eczema, 111-112 (80-1), 200  (175)   bacterial endocarditis, 47-49 (19)  benign prostatic hyperplasia, 207-208  biliary colic, 89 (58), 150  bleeding, 30, 31, 35, 44 (14), 107-8,   114, 158, 201, 212 (185), 216  blurred vision, 42 (11), 91 (59)  bone marrow suppression, 147, 166, 167  (138), 206 (181)  bowel obstruction, 195  bradycardia, 95, 208  bradykinesia, 110 (77, 79)  breast carcinoma, tamoxifen, 104-105  (72)   breathlessness, 30 (1, 2), 93-97 (60-5),  156-157 (127, 128)  bronchoconstriction, anaphylaxis, 91  (59)   anaemia, 201 (176)  breast, 34, 104-105 (72)  colon, 198 (174)  lung, 221   symptoms, 32, 87, 144  terminal, pain, 104-105 (71, 72-73)  candidiasis, oral, 155-156 (126)  cardiac abnormalities, 47-48  cardiac arrest, 33-34 (4)  cardiomegaly, 87 (57), 212-213 (184,  185)   162-3, 198 (174), 201-4 (177-8),  213-6 (186-8) see also congestive  heart failure; ischaemic heart  disease,   cataract, 70, 92 (59),  cellulitis, 97-98 (65-6)  cerebral hypoxia, 90  cerebrovascular disease, 45, 88 (57)  161-3 (133-4), 193 see also  stroke   chronic hepatitis C, 197-198 (174)  chronic myelocytic leukaemia, 32  cirrhosis, (115), 167, 197 (174), see also  hepatic disorders  colonic polyps, 204, (179)  coma, 38, 144, 164, 218   diabetes, 40-2(8-11), 164  congestive heart failure, 38 (7), 45-6  (15-7), 87 (57), 93-97 (60-5),  108-111 (77-80), 162-3 (134),  202 (178), 210-3 (184-6)  consciousness, loss of, 90  constipation, 32, 44-45 (13-14), 101-2,  104 (71, 72), 106, 110, 150-1,  162, 196, 200   cough, 92-3 (60), 151, 166, 220 (190-1)  ACE inhibitors, 46 (15-6), 214  pulmonary oedema, 38 (7), (184)  cramps, 54, 101, 103  Crohn’s disease, 221  Cushing’s disease, 143 (115)  cyanosis, (60), (182-3)  cystitis, 216-218 (188-9)   dehydration, 36-7, 40 (8), 50-1, 101-2,  108-110 (77-8), 214  dementia, 108-111 (77)  dependence, diazepam, 105 (73)  depression, 32, 105 (73), 200-1, 210,  212 (184-6)   108-111 (77-80), 156-161  (127-32), 163-164 (135-6),  210-213 (184-6), 213-216  (186-8), see also hypoglycaemia  C peptide, 194 (171, 172)    corticosteroids, 167, 206  diet, 41 (8, 10), 100-101 (67, 68)  HbAlc, 86 (55-6)  ketoacidosis, 38 (6)  peripheral vascular disease, 105-106  (73-4)   type I, 149 (119)  diaphoresis, 42, 90  diarrhoea, 36 (5), 200-1  drugs, 47 (18), 50-1, 54, 108, 109-10  (79), 144-5, 160, 196, 212  hypokalaemia, 91   dyspnoea, 38 (6, 7), 93-97 (60-5),  151-156 (120-7), 227  dysuria, 216-218 (188-9)   eclampsia, 218, see also pre-eclampsia  eczema, 111-112 (80), 200 (175)  electrolyte imbalance, 109, 34-35, 39,   91 (59), 101-102, 213  emboli, bacterial endocarditis, 49 (20)  encephalopathy, 114  endocarditis, 48-49 (19-20), 103    epilepsy, (58), 88, 99  erythema, 36, 97, 208-209 (182)  extrapyramidal disorders, see movement  disorders   familial colon cancer, 87-88 (57)  fatigue, 32, 165  drugs, 47, 151,   pulmonary oedema, 39  urinary tract infections, 217 (188)  flatulence, 103 (71)  flushing, 54, 158, 214 (187)  foot, diabetes, 105-106 (73-4)  fractures, 32 (3), 199 (175)  frequency, urinary, 216-218 (188-9)  fungal infections, 111 (80)   gallstones, 89 (58), 150 (119)  gastrointestinal disorders, 37, 87-8  drugs, 100, 114 (83), 151, 166 (137),  209   glaucoma, 45 (13-14), 101-103 (70)  beclometasone, 156 (120-1, 126)  corticosteroids, 92 (59)  ipatropium, 153-4 (123)  glue ear, 197 (174)  gout, 49-53 (21-4)   dipyridamole, 44 (14), 212 (185)  gastrointestinal tract, 107 (76), 166  (137)   hallucinations, 42, 169  hayfever, 111, see also allergic rhinitis  headache, 97, 112-4 (81-3), 143-4,  drugs, 33 (4), 42 (11), 43 (12, 13), 47  (18), 54, 95, 144-5, 150-1, 158,  162 (133), 169 (141), 209, 212  hearing loss, 103 (70, 71)  glue ear, 197 (174)  heat stroke, 36-7 (5)  hepatic disorders, 42, 51, 99, 100, 159,  208, 215-6   HIV infection, 37 (6)  hoarseness, beclometasone, 156 (126)  Hodgkin’s disease, 32  hospital-acquired infections, 148 (118)  hot flushes, 34 (4), 104-5 (72), 162  (133), 212   hunger, hypoglycaemia, 91 (59)  hypercalcaemia, 144 (115, 116)  hypercholesterolaemia, 198  hyperglycaemia, 38, 40 (9), 41, 143 — 4,  149, 206, see also diabetes  hyperkalaemia, 91, 160 (131), 227  ACE inhibitors, 96, 160 (131)  angiotensin-II receptor antagonists,  146    perindopril, 203-4 (178)  spironolactone, 45 (15, 16)  hyperlipidaemia, 117, 216  hypernatraemia, 115  hyperparathyroidism, 144 (116), 228  hyperpyrexia, 30   hypersensitivity reactions, 98 (65-6),  228, see also anaphylaxis  hypertension, 93-7 (60-5), 156-61   adrenaline and, 33-4  atenolol dose, 95  diabetes, 91-2 (59)  drugs causing, (126), 150-1 (120)  follow-up, 97 (60-1, 65)  gout, 49-53 (21-4)  organ damage, 88, 208 (182)  pregnancy, 218-9 (189)  hyperthyroidism, 38-9, 54  hypervolaemia, 38-39  hypocalcaemia, disodium pamidronate,  167 (138)   hypoglycaemia, 91 (59), 149, 160  (131), 215 (187), see also  diabetes   amitriptyline, 110 (77, 79)  beta-adrenoceptor blockers, 95 (62)  glibenclamide, 41, 42 (11), 163-4  gliclazide, 100   hypokalaemia, 91 (59), 144-5 (115,  116), 210-1 (184)  arrhythmias, 203  asthma, 153  bisacodyl, 101 (69)  digoxin, 46 (15, 17), 144-145 (115,  116)   salbutamol, 31 (3), 153  hypomagnesaemia, 35 (4)  hypotension, 214 (186, 187)  anaphylaxis, 91 (59)  avoidance in stroke management, 162  (133)   drugs, 96, 158, 203-4, 209 (183),  212, 213 (184, 186),  phenothiazines, 151 (120)  hypothyroidism, 54 (25, 27)   impetigo, 111 (80-1)  incontinence, 110 (79)  infections, 29-30 (1), 195, 197, see also  chest infections  asthma, 92-93 (60)  chemotherapy, 90 (58), 147  cytokine inhibitors and, 167-8 (139)  diabetes, 38 (6), 40-42 (8-11),  105-106 (73-4)   elderly patients, 108-111 (77-80)  eye, corticosteroids and, 92 (59)  fungal, 111 (80)   urinary tract, 216-218 (188-9)  infectious mononucleosis, 29-30  inflammation, 31, 89, 90, 195, 197   colonoscopy, 87-88 (57)  insomnia, 53-4, 95, 98, 105  intestinal obstruction, bisacodyl and,   218-219 (189-90)  iron deficiency anaemia, 29 (1)  irritable bowel syndrome, 200-201  (176), 221   lactic acidosis, 109-10, 159 (130)  leucopenia, 147 (118)  left ventricular hypertrophy, (184, 185)  leukocytosis, 210, 213  loss of consciousness, 90  lower respiratory tract infections see  chest infections   antidepressants, 98-9 (66), 111 (80)  benzodiazepines, 98-9 (66)  elderly patients, 98-9 (66)  orofacial, 98-9 (66)  multiple pathology, elderly patients,  93-97 (60-5)  mumps, 29-30   diabetes, 210-211 (184, 185)  digoxin, 203 (177, 178)  dipyridamole, 162  myopathy, 30 (2), 43, 215-6  myopia, 199 (175)  myositis, 43    nasal congestion, 92-3 (60), 220 (190)  nausea, 38, 93, 96, 143-4, (184)  antivirals, 47 (17, 18), 169 (141)  antidiabetics, 100, 109, 160  anti-emetics, 146-7 (118), 150 (119)  chemotherapy, 90 (58)  colchicine, 51 (23)  cardiovascular drugs, 144-5, 162,   methotrexate, 166, 206-7 (181)  opioids, 104 (72), 106  statins, 43 (13)  necrosis, 147 (118)  nephropathy, diabetes, 91-2  neuralgia, 46-7  neuropathy, 31 (3)  neutropenia, 147, 200  nocturia, diabetes, 40  non-Hodgkin’s lymphoma, 32  nosocomial infections, 148 (118)   oedema, 45 (15), 93-4, 97 (61, 65), 100,  143, 151, 163, 218  oesophageal strictures, 196  oral candidiasis, 155-6 (126)  orofacial unwanted movements, 98-9  ( 66 ) 
PharmacologyByLipincott MCQs clinical pharmacy_djvu.txt