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Question 1
Incorrect
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A 75-year-old man has presented to the clinic with a complaint of disturbed sleep. The physician has prescribed temazepam. Which of the following best describes the mechanism of action of this drug?
Your Answer: Inhibits the effect gamma-aminobutyric acid
Correct Answer: Enhances the effect of gamma-aminobutyric acid
Explanation:Temazepam is an orally available benzodiazepine used in the therapy of insomnia. The soporific activity of the benzodiazepines is mediated by their ability to enhance gamma-aminobutyric acid (GABA) mediated inhibition of synaptic transmission through binding to the GABA-A receptor.The recommended initial dose for insomnia is 7.5 mg before bedtime, increasing as needed to a maximum dose of 30 mg. The most common side effects of temazepam are dose-related and include daytime drowsiness, lethargy, ataxia, dysarthria, and dizziness.Tolerance develops to these side effects, but tolerance may also develop to the effects on insomnia.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 2
Incorrect
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A 27-year-old female diagnosed with rheumatoid arthritis has failed to respond to methotrexate and sulfasalazine. Her GP decides to start her on etanercept injections. Which one among the following is an adverse effect associated with the use of etanercept?
Your Answer:
Correct Answer: Reactivation of tuberculosis
Explanation:Among the give options, reactivation of tuberculosis may occur in a patient under treatment with etanercept.Etanercept is a biological TNF inhibit commonly used to control ankylosing spondylitis, juvenile idiopathic arthritis, plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis.Etanercept is a soluble receptor that binds both TNF-alpha and TNF-beta to inhibit the inflammatory response in joints and skin that is characteristic of these autoimmune disorders.The most common adverse effects include infections (viral, bacterial, and fungal – mostly upper respiratory tract infections) and injection site reaction (erythema, itching, pain, swelling, bleeding, bruising).Rarely it can also cause, reactivation of hepatitis B and TB, pneumocystis pneumonia, congestive cardiac failure, Steven-Johnson syndrome, toxic epidermal necrolysis, etc.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 3
Incorrect
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A 26-year-old student has been brought to the emergency department in a confused state. His friends report that he has been complaining of headaches for the past few weeks. He has a low-grade fever and on examination is noted to have abnormally pink mucosa. What is the most likely diagnosis?
Your Answer:
Correct Answer: Carbon monoxide poisoning
Explanation:Confusion and pink mucosae are typical features of CO poisoning.The patient often presents, most commonly with headaches, and other symptoms like malaise, nausea, and dizziness.Carbon monoxide (CO) poisoning, considered as the great imitator of other diseases as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.Features of carbon monoxide toxicity- Headache: 90% of cases- Nausea and vomiting: 50%- Vertigo: 50%- Confusion: 30%- Subjective weakness: 20%- Severe toxicity: ‘pink’ skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, deathTreatment:Use of Hyperbaric oxygen therapy (HBOT) for treating mild to moderate CO poisoning is not routine.The selection criteria for HBOT in cases of CO poisoning include:• COHb levels > 20-25%• COHb levels > 20% in pregnant patient • Loss of consciousness• Severe metabolic acidosis (pH <7.1)• Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 4
Incorrect
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A 50-year-old male was under treatment for bipolar disease. He was brought to the emergency department as he had become increasingly confused over the past two days. He had vomiting and diarrhoea. He was also consuming and passing a lot of water.On examination, he was disoriented. He had vertical nystagmus and was ataxic.What two investigations are likely to lead to the correct diagnosis?
Your Answer:
Correct Answer: Desmopressin test and serum lithium level
Explanation:Desmopressin test (done to differentiate nephrogenic diabetes insipidus from central diabetes insipidus), and serum lithium levels can together confirm a diagnosis of lithium-induced nephrogenic diabetes insipidus.Bipolar disease is most often managed with mood stabilizers like lithium. This patient develops gastrointestinal symptoms followed by an acute confusional state associated with polyuria and polydipsia. These symptoms are suggestive of diabetes insipidus.In a case where these symptoms occur in a bipolar patient under treatment, lithium-induced nephrogenic diabetes insipidus should be considered as the most probable cause.Lithium intoxication can present with symptoms of nausea, vomiting, mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, especially vertical nystagmus and stupor or coma. Diffuse myoclonic twitching and nephrogenic diabetes insipidus can also occur. Such a clinical syndrome occurs above the serum level of lithium of 1.5–2.0 mEq/L.Management: – Correcting electrolyte abnormalities in patients with acute disease is critical and often life-saving.- Treatment should be initiated with parenteral fluids to replete hypovolemia (normal saline at 200-250 mL/h), followed by administration of hypotonic fluid (0.5% normal saline). – On the restoration of the volume status of the patient forced diuresis should be initiated by the administration of parenteral furosemide or bumetanide accompanied by continued intravenous hypotonic fluid administration to maintain volume status.- Polyuria is managed with hydrochlorothiazide combined with amiloride, acetazolamide.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 5
Incorrect
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A 20-year-old female has been admitted with an acute infection. She gives a history suggestive of hypersensitivity to amoxicillin. After consultation with the allergy specialist, she has now been diagnosed with an IgE mediated penicillin allergy. Which of the following drugs should be avoided in this patient?
Your Answer:
Correct Answer: Cefalexin
Explanation:Cefalexin should be avoided in this patient.This patient is known to have a severe penicillin allergy. None of the above antibiotics are penicillin based. However, 0.5 – 6.5% of patients who are proven to have an IgE mediated penicillin allergy will also be allergic to cephalosporins, including cefalexin. Penicillin, cephalosporins, and carbapenems are all members of the beta-lactam group of antibiotics and share a common beta-lactam ring. There is, therefore, a small risk of allergy cross-over between all these antibiotics. The rates of allergy cross-over are lower with second and third-generation cephalosporins than first-generation cephalosporins such as cefalexin.It is important to question the patient carefully to ascertain what symptoms they had on exposure to penicillin. Symptoms such as an urticarial rash or itching make it more likely that they have an IgE mediated allergy.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 6
Incorrect
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A 53-year-old female teacher asks about hormone replacement therapy (HRT). What is the most compelling indication for starting HRT?
Your Answer:
Correct Answer: Control of vasomotor symptoms such as flushing
Explanation:Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen, combined with a progestogen (in women with a uterus), to help alleviate menopausal symptoms. The main indication is the control of vasomotor symptoms. The other indications, such as reversal of vaginal atrophy and prevention of osteoporosis, should be treated with other agents as first-line therapies.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 7
Incorrect
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Which of the following statements is false regarding the bioavailability of a drug?
Your Answer:
Correct Answer: The bioavailability of a drug given orally is often affected by the degree of renal elimination
Explanation:Renal elimination of a drug has no role in altering the bioavailability of a drug.The bioavailability of a drug is the proportion of the drug which reaches systemic circulation. Mathematically, bioavailability is the AUCoral/AUCiv x 100%, where AUC = area under the concentration-time curve following a single (oral or iv) dose. Other options are true:By definition, the bioavailability of a drug given intravenously is 100%.Drugs given orally that undergo high pre-systemic (first-pass) metabolism in the liver or gut wall have a low bioavailability e.g. lidocaine. Bioavailability is also affected by the degree of absorption from the gut and this can change depending on gut motility and administration of other drugs.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 8
Incorrect
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Which one of the following features is least recognised in long-term lithium use?
Your Answer:
Correct Answer: Alopecia
Explanation:All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 9
Incorrect
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A 76-year-old man has been admitted with a respiratory tract infection. On examination, he was found to be confused and dyspnoeic with O2 saturation of 88%. He has a 60 pack-year smoking history. An arterial blood gas analysis reveals CO2 retention. He has been deemed unfit for admission into the intensive care unit. The physician elects to begin a doxapram infusion. Among the following statements which best fits with the characteristics of doxapram?
Your Answer:
Correct Answer: Epilepsy is a contraindication for doxapram use
Explanation:The statement that fits the characteristics of doxapram is, epilepsy is a contraindication for doxapram use. Concurrent use with theophylline may increase agitation not relaxation.Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma. The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.Drug interactions:Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 10
Incorrect
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A 73-year-old female is being reviewed in the osteoporosis clinic. She had a fracture of her left hip 5 years ago and was started on alendronate. Following the development of persistent musculoskeletal pain, alendronate was replaced with risedronate, which was also stopped for similar reasons. Strontium ranelate was therefore started but was also stopped due to the development of deep vein thrombosis in the right leg. Her current T-score is -4.1. A decision is made to start a trial of denosumab. What is the mechanism of action of denosumab?
Your Answer:
Correct Answer: Inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
Explanation:The principal mechanism by which strontium inhibits osteoclast activity is by enhancing the secretion of osteoprotegerin (OPG) and by reducing the expression of the receptor activator of nuclear factor κB ligand (RANKL) in osteoblasts.Osteoporosis is defined as low bone mineral density caused by altered bone microstructure ultimately predisposing patients to low-impact, fragility fractures.Management:Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D repleteAlendronate is the first-line treatment. Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems. These patients should be offered risedronate or etidronate.Strontium ranelate and raloxifene are recommended if patients cannot tolerate bisphosphonates.Other medications that are useful in the treatment of osteoporosis are denosumab, teriparatide, raloxifene, etc.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 11
Incorrect
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A 62-year-old software developer with lung cancer is currently taking MST 30mg bd for pain relief. What dose of oral morphine solution should he be prescribed for breakthrough pain?
Your Answer:
Correct Answer: 10 mg
Explanation:The total daily morphine dose is 30 x 2 = 60 mg. Therefore, the breakthrough dose should be one-sixth of this, 10 mg.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 12
Incorrect
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According to the Vaughan William's classification of antiarrhythmic agents, lidocaine is a:
Your Answer:
Correct Answer: Class Ib agent
Explanation:Lidocaine is an example of class IB antiarrhythmics.The Vaughan-Williams classification of antiarrhythmicsI: Membrane stabilizing agentsIA: Quinidine, Procainamide, DisopyramideIB: Lidocaine, MexiletineIC: Propafenone, Flecainide II: β blockers – Propranolol, EsmololIII: Agents widening AP – Amiodarone, Dronedarone, Dofetilide, Ibutilide, SotalolIV: Calcium channel blockers – Verapamil, DiltiazemV: Miscellaneous – Digoxin, adenosine, magnesium
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 13
Incorrect
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What is the mechanism of action of sildenafil citrate?
Your Answer:
Correct Answer: Inhibition of phosphodiesterase V
Explanation:Sildenafil citrate (Viagra) is the first oral drug to be widely approved for the treatment of erectile dysfunction. It is a potent and selective inhibitor of type-V phosphodiesterase, the primary form of the enzyme found in human penile erectile tissue, thereby preventing the breakdown of cyclic guanosine monophosphate (cGMP), the intracellular second messenger of nitric oxide.Uses:It is used for the treatment of erectile dysfunction, idiopathic pulmonary hypertension, premature ejaculation, high altitude illness, penile rehabilitation after radical prostatectomy, angina pectoris, and lower urinary tract symptoms.Adverse effects:Mild headache, flushing, dyspepsia, cyanopsia, back pain, and myalgias – due to a high concentration of PDE11 enzyme in skeletal muscle, which shows significant cross-reactivity with the use of tadalafil.It can also cause hypotension, dizziness, and rhinitis.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 14
Incorrect
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A 25-year-old male presented to accident and emergency 4 days ago, following an intentional paracetamol overdose. He had taken 20x 500mg tablets, all at once. He denies any alcohol intake. Blood investigations 4 hours after ingestion showed:Paracetamol: 14 mg/lINR: 1Liver enzymes: No abnormality detectedBilirubin: Mild elevationHe was seen by the mental health team and discharged. The blood investigations were repeated:Bilirubin: Within normal limitsUrea: 21 mmol/lCreatinine: 300 µmol/lWhat is the likely cause of these results?
Your Answer:
Correct Answer: Delayed paracetamol nephrotoxicity
Explanation:The most likely cause for these results is delayed paracetamol nephrotoxicity.The blood investigations of this patient are highly suggestive of acute kidney injury. Paracetamol overdose is well known to cause hepatotoxicity, but not for its delayed nephrotoxicity, especially in significant overdose. Appropriate monitoring of a patient’s blood tests is important.Management:NAC (N-Acetyl cysteine) has a clear role in preventing acetaminophen-induced liver necrosis. Although NAC has not been proven to be harmful to the kidney, its role in patients without hepatoxicity and only isolated renal dysfunction is uncertain.Other options:-There are no features in the history that are suggestive of dehydration and pre-renal AKI presenting in this manner in a 25-year-old would be very unusual.- Minimal change nephropathy typically presents with a nephrotic picture of kidney injury.- Berger’s more commonly presents with isolated haematuria.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 15
Incorrect
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A 51-year-old real estate agent takes hydrocortisone 20mg in the mornings and 5mg at night for Addison’s disease. The endocrinology consultant would like her to take prednisolone instead. What dose of prednisolone should be started?
Your Answer:
Correct Answer: 7 mg
Explanation:1mg Prednisolone = 4mg hydrocortisone, so the actual equivalent daily dose is 7mg.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 16
Incorrect
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Which of the following is the most common clinical feature of carbon monoxide poisoning?
Your Answer:
Correct Answer: Headache
Explanation:Carbon monoxide (CO) poisoning:It is considered as the great imitator of other diseases as the patients present with a myriad of symptoms. The carbon monoxide diffuses rapidly across the pulmonary capillary membrane binding to the haem molecule with a very high affinity (240 times that of oxygen) forming carboxy-haemoglobin (COHb). Non-smokers have a baseline COHb of ,3% while smokers have a baseline COHb of 10-15%.Clinical features of carbon monoxide toxicity:Headache: 90% of cases (most common clinical feature)Nausea and vomiting: 50%Vertigo: 50%Confusion: 30%Subjective weakness: 20%Severe toxicity: ‘pink’ skin and mucosa, hyperpyrexia, arrhythmias, extrapyramidal features, coma, deathCherry red skin is a sign of severe toxicity and is usually a post-mortem finding.Management• 100% oxygen• Hyperbaric oxygen therapy (HBOT)The use of Hyperbaric oxygen therapy (HBOT) for treatment mild to moderate CO poisoning is not routine.The selection criteria for HBOT in cases of CO poisoning include:• COHb levels > 20-25%• COHb levels > 20% in pregnant patient • Loss of consciousness• Severe metabolic acidosis (pH <7.1)• Evidence of end-organ ischemia (e.g., ECG changes, chest pain, or altered mental status)
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 17
Incorrect
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A 35-year-old male was brought to you in a confused state. Although not your patient, you can make out that the man has a history of schizophrenia, and has recently had his medications altered. Clinically, you find evidence of a lower respiratory tract infection, and blood investigations indicate a neutropenic picture.What is the most likely drug causing the neutropenia?
Your Answer:
Correct Answer: Clozapine
Explanation:Clozapine can cause neutropenia or agranulocytosis.Clozapine is an atypical antipsychotic used in the treatment of schizophrenia, and in patients who are intolerant to, or unresponsive to other antipsychotics. It is a weak D2-receptor and D1-receptor blocking activity, with noradrenolytic, anticholinergic, and antihistaminic properties.Many antipsychotic drugs can occasionally cause bone marrow depression, but agranulocytosis is particularly associated with clozapine.Other side effects include:Hypotension, tachycardiaFever, sedation, seizures (with high doses)Appetite increaseConstipationHeartburnWeight gainExtrapyramidal symptomsAgranulocytosisNeuroleptic malignant syndrome
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 18
Incorrect
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A 60-year-old male is under treatment with azathioprine after a renal transplant. During his review, he complains of pain and swelling over his left great toe. Investigations reveal hyperuricemia. Suspecting gout, he was started on allopurinol. Subsequently, he develops aplastic anaemia. Which of the following is the most appropriate reason for his bone marrow failure?
Your Answer:
Correct Answer: Mercaptopurine toxicity
Explanation:The cause for bone marrow suppression in this patient is most probably mercaptopurine toxicity.Azathioprine is metabolized to 6-mercaptopurine (6-MP), which itself is metabolized by xanthine oxidase. Xanthine oxidase inhibition by allopurinol leads to the accumulation of 6-MP which then precipitates bone marrow failure. This may be potentially fatal if unrecognized.Clinical presentation:Toxicity symptoms include gastrointestinal symptoms, bradycardia, hepatotoxicity, myelosuppression.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 19
Incorrect
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Which of the following is a characteristic clinical finding of opioid poisoning?
Your Answer:
Correct Answer: Bradycardia
Explanation:Opioid poisoning is classically associated with pinpoint pupils, reduced respiratory rate, bradycardia, drowsiness and coma. Hypothermia is a feature of barbiturate poisoning, while sweating and lacrimation are seen in cases of opiate withdrawal.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 20
Incorrect
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Which one of the following antibiotics is safest to use in pregnancy?
Your Answer:
Correct Answer: Erythromycin
Explanation:Antibiotics that should be avoided in pregnancy are included in the mnemonic: Countless SAFe Moms Take Really Good Care -Clarithromycin, Sulphonamides, Aminoglycosides, Fluoroquinolones, Metronidazole, Tetracyclines, Ribavirin, Griseofulvin, Chloramphenicol
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 21
Incorrect
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A 70-year-old male with advanced COPD currently on treatment with salbutamol (as required) presents for review. After a complete history and examination, you conclude that he requires to be stepped up in his inhalational therapy. The decision to add tiotropium bromide to his regime was taken. Which of the following best describe the mechanism of action of tiotropium?
Your Answer:
Correct Answer: It is a long-acting anticholinergic agent
Explanation:Tiotropium is a specific long-acting antimuscarinic agent indicated as maintenance therapy for patients with COPD (chronic obstructive pulmonary disease). It should be used cautiously in patients with narrow-angle glaucoma, prostatic hyperplasia or bladder neck obstruction.The most frequently encountered adverse effects of tiotropium include pharyngitis, bronchitis, sinusitis, dry mouth, cough, and headaches. Paradoxical bronchospasm may also occur as a rare side-effect. Dry mouth occurs in up to 14% of patients taking tiotropium, in keeping with its anticholinergic profile. Rarer side-effects include tachycardia, blurred vision, urinary retention, and constipation.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 22
Incorrect
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Which of the following is not a cause of drug-induced hepatitis?
Your Answer:
Correct Answer: Ethambutol
Explanation:Although rare, ocular toxicity in the form of optic neuritis (most commonly retrobulbar neuritis) has been well documented as a side effect of ethambutol. It is renally excreted and not associated with hepatitis.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 23
Incorrect
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A 56-year-old male presents to the emergency department with confusion and agitation for the past four hours. He is a known alcoholic who has abstained from drinking for the past three days.On examination, he is sweating, agitated and disorientated. His temperature is 37.7°C, pulse 112 bpm regular and blood pressure is 150/76 mmHg. Blood investigations performed in the emergency department reveal:FBC: NormalU&E: NormalPlasma glucose: 4.6 mmol/l (3.6-6)Which of the following medications would be the most appropriate treatment for this man?
Your Answer:
Correct Answer: Oral lorazepam
Explanation:The most probable diagnosis for this patient is delirium tremens due to alcohol withdrawal, which should be treated as a medical emergency. Delirium tremens is a hyperadrenergic state and is often associated with tachycardia, hyperthermia, hypertension, tachypnoea, tremor, and mydriasis.Treatment:- The most common and validated treatment for alcohol withdrawal is benzodiazepine: first-line treatment includes oral lorazepam. – If the symptoms persist, or the medication is refused, parenteral lorazepam, haloperidol or olanzapine should be given.- Central-acting, alpha-2 agonists such as clonidine and dexmedetomidine should not be used alone for the treatment of alcohol withdrawal.- It is also recommended to avoid using alcohol, antipsychotics, anticonvulsants, beta-adrenergic receptor blockers, and baclofen for the treatment of alcohol withdrawal as there are not enough studies to support the safety of these.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 24
Incorrect
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A 34-year-old man was brought to the ER following a road-traffic-accident. An X-ray of his left thigh revealed a fractured shaft of the left femur. He has a known history of opioid abuse. You are called to the ward to assess him after he becomes unwell. Which of the following clinical features are NOT compatible with a diagnosis of opioid withdrawal?
Your Answer:
Correct Answer: Hypothermia
Explanation:Among the options provided, hypothermia is not a symptom of opioid withdrawal.Symptoms of opioid withdrawal include dysphoric mood, yawning, insomnia, muscle aches, lacrimation/rhinorrhoea, papillary dilatation, piloerection, fever, sweating, nausea/vomiting, diarrhoea.If the patient is having an opioid withdrawal reaction, then give 10 mg of methadone syrup and wait about 60 min to determine its effect.COWS (Clinical Opioid Withdrawal Scale) assessment for opioid withdrawal is commonly used to determine the severity of opioid withdrawal.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 25
Incorrect
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In the event of an overdose, haemodialysis is ineffective as a treatment modality for which of the following drugs?
Your Answer:
Correct Answer: Tricyclics
Explanation:Tricyclic compounds can’t be cleared by haemodialysis.Drugs that can be cleared with haemodialysis include: (BLAST)- Barbiturate- Lithium- Alcohol (inc methanol, ethylene glycol)- Salicylates- Theophyllines (charcoal hemoperfusion is preferable)Drugs which cannot be cleared with haemodialysis include:- Tricyclics- Benzodiazepines- Dextropropoxyphene (Co-proxamol)- Digoxin- Beta-blockers
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 26
Incorrect
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Which of the following is correct regarding lead poisoning?
Your Answer:
Correct Answer: Causes a peripheral neuropathy due to demyelination
Explanation:Lead can be absorbed through the skin and by inhalation. It is associated with iron deficiency and a microcytic anaemia. The most common gastrointestinal symptoms are abdominal colic and constipation.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 27
Incorrect
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A 50-year-old man is admitted with nausea and excessive drowsiness after taking an antihistamine tablet with grapefruit juice. Which of the following liver enzyme systems is affected by grapefruit juice causing the given side effect?
Your Answer:
Correct Answer: Cytochrome p450 3A4
Explanation:The cytochrome p450 3A4 enzyme system in the liver is affected by grapefruit juice. Patients taking antihistamines should be advised to avoid drinking grapefruit juice. This is because constituents of grapefruit juice such as naringin and bergamottin inhibit CYP3A4 in the liver, particularly at high doses, leading to decreased drug elimination via hepatic metabolism and can increase potential drug toxicities. Inhibition of this enzyme system leads to reduced metabolism of antihistamines leading to an increased incidence of side effects like excessive drowsiness and nausea as in this patient.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 28
Incorrect
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A 35-year-old woman under treatment for long-term epilepsy with valproate presented with complaints of excessive weight gain. She is consuming oral contraceptive pills.Which among the following is the best alternative to valproate for treating long-term epilepsy?
Your Answer:
Correct Answer: Lamotrigine
Explanation:Among the given anti-epileptics the best drug that can be given in this patient is lamotrigine.Topiramate, carbamazepine, phenytoin, and phenobarbital are all hepatic enzyme inducers and are associated with decreased effectiveness of the oral contraceptive (OCP) due to acceleration of the metabolism of oestrogens and progestogens.If she is planning on pregnancy then registry studies suggest that lamotrigine would also be the best choice.Other hepatic enzyme inducers include rifampicin, spironolactone, griseofulvin, etc.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 29
Incorrect
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A 45-year-old woman has been diagnosed with T1N1M1 malignancy in the left breast, with metastases detectable in the lower thoracic vertebrae and the left lung. Before the initiation of treatment of this patient with trastuzumab, which is the most important investigation to perform?
Your Answer:
Correct Answer: Echo
Explanation:Before the initiation of trastuzumab, an echocardiography is a must to rule out any pre-existing cardiac abnormalities as trastuzumab is cardiotoxic.Trastuzumab (Herceptin) is a monoclonal antibody directed against the HER2/neu receptor. It is used mainly in metastatic breast cancer although some patients with early disease are now also given trastuzumab.Adverse effects include:Flu-like symptoms and diarrhoea are common.Cardiotoxicity: – Risk increases when anthracyclines are used concomitantly. – Trastuzumab-induced cardiac dysfunctions are regarded as less severe and largely reversible because primary cardiomyocyte do not show ultrastructure changes unlike those associated with anthracycline-induced cardiotoxicity. – Primary myocyte injury does not occur in patients who were treated with trastuzumab.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 30
Incorrect
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What is the rationale concerning the use of sodium cromoglycate in the prophylaxis of bronchial asthma?
Your Answer:
Correct Answer: Inhibition of mast-cell degranulation
Explanation:Sodium cromoglycate principally acts by inhibiting the degranulation of mast cells triggered by the interaction of antigen and IgE. The inhibitory effect on mast cells appears to be cell-type specific since cromoglycate has little inhibitory effect on mediator release from human basophils.Thus, it inhibits the release of histamine, leukotrienes, and slow-reacting substance of anaphylaxis from mast cells by inhibiting degranulation following exposure to reactive antigens.Adverse effects include cough, flushing, palpitation, chest pain, nasal congestion, nausea, fatigue, migraine, etc.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 31
Incorrect
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Question 32
Incorrect
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A 22-year-old university student is admitted after taking drugs at a night club. Which of the following features suggest she had taken ecstasy (MDMA)?
Your Answer:
Correct Answer: A pyrexia of 40°C
Explanation:MDMA commonly known as ecstasy or molly, is a psychoactive drug primarily used as a recreational drug. The desired effects include altered sensations, increased energy, empathy, and pleasure. Features of MDMA abuse include hyponatraemia, tachycardia, hyperventilation, and hyperthermia.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 33
Incorrect
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A 50-year-old woman under treatment for manic-depressive psychosis presents in an unconscious state after an episode of seizure on the street. Her husband who accompanied her into the ER reported that they argued about 6-7 hours ago. On examination, she is found to be hypertonic with a GCS of 8, BP: 90/60 mmHg and a pulse of 105 bpm. Blood investigations revealed a lithium level of 3.2 mmol/L. She was intubated and ventilated. Which of the following is the most appropriate immediate management in this case?
Your Answer:
Correct Answer: N saline should be started iv
Explanation:- Normal saline (N saline) should be started IV: Intravenous normal saline is recommended to enhance renal excretion of lithium. Adequate hydration is crucial because lithium is primarily excreted by the kidneys, and maintaining good urine output can help reduce lithium levels.
- Dialysis: This is considered the most effective treatment for severe lithium toxicity, especially when serum levels are significantly elevated (typically >2.5 mmol/L) and the patient presents with severe symptoms such as seizures, altered mental status, or renal impairment. Given the patient’s lithium level of 3.2 mmol/L and her critical condition, dialysis is necessary to rapidly reduce lithium levels.
The other options are less appropriate or ineffective in this context:
- Gastric lavage should be considered: This is not typically recommended for lithium poisoning because lithium is rapidly absorbed and lavage is unlikely to be effective several hours post-ingestion.
- Activated charcoal is likely to be effective: Activated charcoal does not effectively bind lithium and is not recommended for lithium poisoning.
- 5% dextrose should be started IV: While maintaining hydration is important, normal saline is preferred over dextrose solutions in this context to promote renal excretion of lithium.
- Dialysis is not normally required unless levels are above 5 mmol/L: This statement is incorrect. Dialysis is often required at lower levels, particularly in cases of severe toxicity or if the patient is symptomatic, as seen in this case.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 34
Incorrect
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A 48-year-old male with a history of bipolar disorder presents with acute confusion. In-transit to hospital he had a generalized seizure which terminated spontaneously after around 30 seconds. On arrival to the emergency department, his GCS is 14/15 and he is noted to have a coarse tremor. Suspecting a diagnosis of lithium toxicity, intravenous access is obtained, a blood sample was drawn for investigations and a saline infusion is started. The blood investigations revealed:Lithium level: 4.2 mmol/lNa+: 136 mmol/lK+: 4.6 mmol/lUrea: 8.1 mmol/lCreatinine: 99 µmol/lBicarbonate: 18 mmol/lWhat is the most appropriate management for the patient?
Your Answer:
Correct Answer: Arrange haemodialysis
Explanation:The presentation of the patient is typical of chronic lithium toxicity (due to the presence of mainly neurological manifestations). Additional to the blood investigations mentioned, urine analysis, electrolyte levels, and renal function should also be performed. A low urine Anion gap and a low urine specific gravity are highly suggestive of lithium toxicity.ECG obtained in this patient is likely to show: nonspecific, diffuse ST segment depression with T wave inversion.Acute lithium toxicity presents with more GI manifestations while, the clinical features of chronic lithium toxicity are mainly neurological and can include:Coarse tremors (fine tremors are seen in therapeutic levels), hyperreflexia, acute confusion, seizures, and coma.The management of lithium toxicity is as follows:Immediate GI decontamination with gastric lavage (in case of acute intoxication)Saline Administrations: the goal of saline administration is to restore GFR, normalize urine output and enhance lithium clearance.Haemodialysis remains the mainstay treatment for lithium toxicity as lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP Workgroup) recommendations for dialysis (extracorporeal treatment) in lithium toxicity include:• Impaired kidney function and lithium levels > 4.0 mEq/L• Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels• Levels are > 5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hoursAs post-dialysis rebound elevations in lithium levels have been documented, continuous veno-venous hemofiltration (CVVH) has been advocated.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 35
Incorrect
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Which one of the following features is least recognised in long-term lithium use?
Your Answer:
Correct Answer: Alopecia
Explanation:All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium.Common lithium side effects may include:- dizziness, drowsiness;- tremors in your hands;- trouble walking;- dry mouth, increased thirst or urination;- nausea, vomiting, loss of appetite, stomach pain;- cold feeling or discoloration in your fingers or toes;- rash; or.- blurred vision.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 36
Incorrect
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A 47-year-old male with type II diabetes mellitus presents to your clinic with a history suggestive of erectile dysfunction. You decide to start him on sildenafil citrate. What is the mechanism of action of this drug?
Your Answer:
Correct Answer: Phosphodiesterase type V inhibitor
Explanation:Sildenafil (Viagra) is a phosphodiesterase type V inhibitor used in the treatment of impotence.Contraindications:- Patients taking nitrates and related drugs such as nicorandil- Hypotension- Recent stroke or myocardial infarction (NICE recommend waiting 6 months)Side-effects:Visual disturbances e.g. cyanopsia, non-arthritic anterior ischaemic NeuropathyNasal congestionFlushingGastrointestinal side-effectsHeadache
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 37
Incorrect
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Which of the following drug can cause galactorrhoea?
Your Answer:
Correct Answer: Metoclopramide
Explanation:Metoclopramide causes extrapyramidal effects (especially in children and young adults), hyperprolactinaemia, and occasionally tardive dyskinesia on prolonged administration. Also reported are drowsiness, restlessness, diarrhoea, depression, neuroleptic malignant syndrome, rashes, pruritus, oedema.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 38
Incorrect
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A 25-year-old female presents to the emergency department with severe breathlessness and tinnitus. She is under treatment for asthma and depression with albuterol and amitriptyline respectively.On examination, she seems agitated with a BP of 100/44, a pulse rate of 112 bpm, a respiratory rate of 30 cycles/min, and a temperature of 37.8'C.An arterial blood gas performed reveals:pH: 7.48 (7.36 – 7.44)pO2: 11.2 kPa (11.3 – 12.6 kPa)pCO2: 1.9 kPa (4.7 – 6.0 kPa)Bicarbonate: 13 mmol/l (20 – 28 mmol/L)What is the most probable diagnosis?
Your Answer:
Correct Answer: Salicylate poisoning
Explanation:The blood gas analysis provided above is suggestive of a mixed respiratory alkalosis and metabolic acidosis characteristic of salicylate overdose.Pathophysiology:The direct stimulation of the cerebral medulla causes hyperventilation and respiratory alkalosis.As it is metabolized, it causes an uncoupling of oxidative phosphorylation in the mitochondria. Lactate levels then increase due to the increase in anaerobic metabolism. This, along with a slight contribution from the salicylate metabolites result in metabolic acidosis.Tinnitus is characteristic and salicylate ototoxicity may produce deafness. Other neurological sequelae include encephalopathy and agitation, seizures and CNS depression and coma. Cardiovascular complications include tachycardia, hypotension, and dysrhythmias (VT, VF, and asystole).
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 39
Incorrect
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A 18-year-old girl is brought to A&E having ingested at least 16 tablets of paracetamol 8 hours earlier. What should her immediate management consist of?
Your Answer:
Correct Answer: Intravenous N-acetylcysteine
Explanation:Activated charcoal is useful if given within one hour of the paracetamol overdose. Liver function tests, INR and prothrombin time will be normal, as liver damage may not manifest until 24 hours or more after ingestion.The antidote of choice is intravenous N-acetylcysteine, which provides complete protection against toxicity if given within 10 hours of the overdose.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 40
Incorrect
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A 18-year-old female is brought to the emergency department by her boyfriend. He is concerned that she may have taken an overdose of her mom's morphine sulphate pills after being depressed about her mother, who is dying of carcinoma of the breast.Which of the following may point towards his suspicion?
Your Answer:
Correct Answer: Sweating
Explanation:Excessive sweating points towards a morphine overdose.Morphine is considered the classic opioid analgesic with which other painkillers are compared. Like other medications in this class, morphine has an affinity for delta, kappa, and mu-opioid receptors.Most commonly used in pain management, morphine provides major relief to patients afflicted with pain.Among the more common adverse effects of morphine use is constipation. Other side effects include nausea, vomiting, drowsiness, and confusion. Psychological and physical dependence may occur.Other side effects include bronchospasm, angioedema, urinary retention, ureteric or biliary spasm, dry mouth, sweating, rash, facial flushing, vertigo, tachycardia, bradycardia, palpitations, orthostatic hypotension, hypothermia, restlessness, mood change, hallucinations, seizures (adults and children) and miosis, headache and allergic reactions (including anaphylaxis) and decreased libido or potency.Raised intracranial pressure occurs in some patients. Muscle rigidity may occur with high doses. Elevated liver enzymes may occur due to biliary sphincter constriction. Large doses can lead to respiratory depression, circulatory failure, and coma.Treatment of opioid overdose:Initial treatment of overdose begins with supportive care.Naloxone is a pure competitive antagonist of opiate receptors and has no agonistic activity. The drug is relatively safe and can be administered intravenous, intramuscular, subcutaneous or via the endotracheal tube.Alternatively, nalmefene and naltrexone maybe considered.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 41
Incorrect
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What is the mode of action of amiodarone?
Your Answer:
Correct Answer: Potassium channel blocker
Explanation:Amiodarone is a class III antiarrhythmic drug. Class III antiarrhythmics are potassium channel blockers, they prolong duration of action potential with resulting prolongation of effective refractory period.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 42
Incorrect
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A 45-year-old male is brought to the emergency department after being found collapsed, outside a nightclub. The ER team found an empty bottle of amyl nitrate in his pocket. The patient is hypoxic with an O2 saturation of 84% and is confused. Which of the following is the best treatment for this patient?
Your Answer:
Correct Answer: Methylene blue
Explanation:The best treatment for the patient in question would be methylene blue.The most probable diagnosis in this patient is methemoglobinemia due to the ingestion of amyl nitrate.Amyl nitrate promotes the formation of methaemoglobin, which avidly conserves oxygen and leads to decreased tissue oxygen saturations. Treatment of choice includes methylene blue and vitamin C.Adverse effects:Benign side effects include green or blue discoloration of urine and patients should be forewarned. Significant side effects are based on methylene blue, itself, being an oxidizing agent and an inhibitor of monoamine oxidase A (MAO-A). As an oxidizing agent, methylene blue can actually precipitate methemoglobinemia or haemolysis in high doses or when ineffectively reduced. Methylene blue administration in a patient taking a serotonergic agents may predispose to serotonin syndrome.Note: Although methylene blue administration is controversial in the setting of G6PD-deficiency due to reduced levels of NADPH, it is not contraindicated and should be administered cautiously and judiciously.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 43
Incorrect
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A 78-year-old male with long-standing Alzheimer's disease is being reviewed in your clinic. Which among the following is true regarding memantine, a drug which has been approved for the management of dementia?
Your Answer:
Correct Answer: It is an NMDA-receptor antagonist
Explanation:Memantine is an antagonist of the NMDA (N-Methyl-D-Aspartate)-receptor subtype of glutamate receptor. It is used to slow the neurotoxicity thought to be involved in Alzheimer’s disease and other neurodegenerative diseases.
Drug interactions:
- When given concomitantly with other NMDA-receptor antagonists (e.g., ketamine, amantadine) there is increased risk of psychosis.
- Dopamine agonists, L-dopa, and anticholinergics enhance effects of memantine.
- Antispasmodics (e.g., baclofen) enhance effects, as memantine has some antispasmodic effects.
- Drugs excreted by cationic transporters in the kidney (e.g. quinine, cimetidine, ranitidine) reduce excretion.
- Common adverse effects include dizziness, headache, confusion, diarrhoea, and constipation.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 44
Incorrect
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An 80-year-old woman with advanced COPD has been admitted to the medicine ward in an unconscious state. She appears to have an acute lower respiratory tract infection. After consulting with an anaesthesiologist it was concluded that she was not a candidate for intensive care unit admission and thus, a decision was made to start the patient on doxapram therapy. Which of the following best fits the characteristics of doxapram?
Your Answer:
Correct Answer: It is contraindicated in hyperthyroidism
Explanation:The two statements that fit the characteristics of doxapram are, epilepsy is a contraindication for doxapram use and concurrent use with theophylline may increase agitation.Doxapram is a central respiratory stimulant. In clinical practice, doxapram is usually used for patients who have an acute exacerbation of chronic obstructive pulmonary disease (COPD) who are unsuitable for admission to the intensive therapy unit for ventilatory support. Doxapram infusion may buy an extra 24 h to allow for recovery.Contraindications include: ischaemic heart disease, epilepsy, cerebral oedema, acute stroke, asthma, hypertension, hyperthyroidism, and pheochromocytoma. The infusion may worsen agitation and dyspnoea and lead to hypertension, nausea, vomiting and urinary retention.Drug interactions:Concomitant administration of doxapram and aminophylline (theophylline) can cause increased skeletal muscle activity, agitation, and hyperactivity.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 45
Incorrect
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A 27-year-old male is admitted after drinking engine coolant in an apparent suicide attempt. Lab investigations reveal:
- pH 7.1 (7.36-7.44)
- pO2 15.3 kPa (11.3-12.6)
- pCO2 3.2 kPa (4.7-6.0)
- Standard bicarbonate 2.2 mmol/L (20-28)
- Serum calcium 1.82 mmol/L (2.2-2.6)
Your Answer:
Correct Answer: Fomepizole infusion
Explanation:The patient’s symptoms and lab results are indicative of ethylene glycol poisoning, commonly found in engine coolant. Ethylene glycol is metabolized to toxic metabolites, including glycolic acid and oxalic acid, which can cause metabolic acidosis (evidenced by the low pH and low bicarbonate levels) and can bind calcium, leading to hypocalcemia.
Fomepizole is an antidote that inhibits alcohol dehydrogenase, the enzyme that converts ethylene glycol into its toxic metabolites. This prevents further formation of the harmful substances, allowing time for the ethylene glycol to be excreted unchanged in the urine.
While haemodialysis is also an important treatment for severe ethylene glycol poisoning, especially in cases of significant acidosis or renal failure, the immediate administration of fomepizole is the most urgent intervention to prevent further toxicity. Haemodialysis can be considered if the patient does not respond adequately to fomepizole or if there are signs of severe toxicity.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 46
Incorrect
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Which among the following antihypertensives is centrally acting?
Your Answer:
Correct Answer: Moxonidine
Explanation:Moxonidine and alpha-methyl dopa are centrally acting antihypertensives and modify blood pressure through modifying sympathetic activity.Other options:Verapamil is a calcium antagonist.Minoxidil and hydralazine are both vasodilators.Phenoxybenzamine is an alpha-blocker.Adverse effects:Dry mouth and somnolence were the most frequently reported adverse events, followed by headache, dizziness, nausea and allergic skin reactions.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 47
Incorrect
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A 50-year-old male presents to the ER allegedly claiming that he consumed a bottle of antifreeze. Which of the following symptoms is least likely to be associated with this kind of poisoning?
Your Answer:
Correct Answer: Hypertension
Explanation:Loss of vision after consumption of antifreeze is a characteristic presentation of methanol poisoning.
Pathophysiology of methanol toxicity: When ingested, methanol is absorbed rapidly via the gastrointestinal tract in less than 10 minutes. Methanol is not protein-bound and is absorbed directly into the total body water compartment. Metabolism occurs mainly in the liver through serial oxidation via alcohol dehydrogenase and aldehyde dehydrogenase but begins with alcohol dehydrogenase present in the gastric mucosa. Alcohol dehydrogenase oxidizes methanol to formaldehyde, and aldehyde dehydrogenase subsequently oxidizes formaldehyde to formic acid. Formic acid is the primary toxic metabolite that accounts for the associated anion gap metabolic acidosis and end-organ damage.
Clinical presentation: Patients who present within the first 12 to 24 hours following ingestion may appear normal, and this is described as the latent period. Nausea, vomiting, and abdominal pain subsequently ensue, followed by CNS depression and hyperventilation due to metabolic acidosis. Ocular symptoms associated with retinal toxicity are often evident in the form of blurry vision, decreased visual acuity, photophobia, and “halo vision.”
Treatment: Treatment options for methanol toxicity include supportive care, fomepizole (Antizole, 4-Methylpyrazole or 4MP), ethanol, dialysis, and folate.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 48
Incorrect
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A 23-year-old female known with schizophrenia is being reviewed in the emergency department. Her mother claims that she has been 'staring' for the past few hours but has now developed abnormal head movements and has gone 'cross-eyed'. On examination, the patient's neck is extended and positioned to the right. Her eyes are deviated upwards and are slightly converged. Given the likely diagnosis, what is the most appropriate treatment?
Your Answer:
Correct Answer: Procyclidine
Explanation:The most probable diagnosis in this patient is an oculogyric crisis, that is most appropriately managed with procyclidine or benztropine (antimuscarinic). An oculogyric crisis is a dystonic reaction to certain drugs or medical conditions.Features include:Restlessness, agitationInvoluntary upward deviation of the eyesCauses:PhenothiazinesHaloperidolMetoclopramidePostencephalitic Parkinson’s diseaseManagement:Intravenous antimuscarinic agents like benztropine or procyclidine, alternatively diphenhydramine or ethopropazine maybe used.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 49
Incorrect
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A 30-year-old male with a history of premature cardiovascular disease in the family has come for review of his lab investigations. His fasting cholesterol is 8.4 mmol/l with high-density lipoprotein (HDL) of 1.6 mmol/l. You elect to commence him on atorvastatin 20 mg PO daily.Which of the following best describes the mechanism of action of the statins?
Your Answer:
Correct Answer: They inhibit HMG CoA reductase
Explanation:Statins are a selective, competitive inhibitor of hydroxymethylglutaryl-CoA (HMG-CoA) reductase, which is the enzyme responsible for the conversion of HMG-CoA to mevalonate in the cholesterol synthesis pathway.Statins are usually well tolerated with myopathy, rhabdomyolysis, hepatotoxicity, and diabetes mellitus being the most common adverse reactions. This is the rate-limiting step in cholesterol synthesis, that leads to increased hepatic low-density lipoprotein (LDL) receptors and reduced hepatic VLDL synthesis coupled with increased very-low-density lipoprotein (VLDL) clearance.
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This question is part of the following fields:
- Medicine
- Pharmacology
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Question 50
Incorrect
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A 70-year-old man presents with nocturia, hesitancy and terminal dribbling of urine. Prostate examination reveals a moderately enlarged prostate with no irregular features and a well-defined median sulcus. Blood investigations show a PSA level of 1.3 ng/mL. Among the options provided below what is the most appropriate management for this patient?
Your Answer:
Correct Answer: Alpha-1 antagonist
Explanation:Benign Prostatic Enlargement or Hyperplasia (BPE/BPH) is the most probable diagnosis of the patient in question. It is a histological diagnosis characterized by proliferation of the cellular elements of the prostate. The initial treatment modality of choice is selective alpha 1 antagonists (such as Prazosin, Alfuzosin and Indoramin, and long acting agents like, Terazosin, Doxazosin, etc.) as they provide immediate relief from the bothersome lower urinary tract symptoms (LUTS).Other treatment modalities include:• Non-selective alpha blockers: no longer used due to severe adverse effects and the availability of selective alpha 1 blockers.• 5 alpha reductase inhibitors: Finasteride and Dutasteride, they target the underlying disease process and reduce the overall prostate volume. Thus, reduce the urinary retention and the lower urinary tract symptoms. (They do not provide immediate relief from LUTS and thus are not preferred as first line drugs over alpha 1 antagonists)• PDE-5 Inhibitors: The long-acting tadalafil has proven to be useful.• Surgical Treatment modalities: TURP, Prostatectomy, etc.
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This question is part of the following fields:
- Medicine
- Pharmacology
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SESSION STATS - PERFORMANCE PER SPECIALTY
