AKT Exam Questions

Theme: All the patients have recently been discharged from hospital. Match the patient scenarios below to a chosen option

1. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a knee replacement on Diclofenac 50mg tds as well as her other medications.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: B

Stop the Diclofenac which has dangerous interactions with Warfarin and could potentially exacerbate renal problems in association with Ramipril.

2. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a chest infection on Erythromycin 500mg qds as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Erythromycin potentiates the action of warfarin but is presumably essential for whatever reason. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

3. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She is discharged from hospital following a UTI on Ciprofloxacin 500mg bd as well as her other medications

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Ciprofloxacin potentiates the action of warfarin but is presumably essential. In chronic AF, stopping Warfarin in the short term is unlikely to do harm. It can be restarted when the antibiotics cease. The INR should be checked immediately.

4. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She was admitted with a fall and is continuing to do so.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: C

Persistent falls contra-indicate Warfarin. IN this case it is important however to exclude arrthymias (especially bradycardias with bisoprolol) and postural hypotension.

5. An 80 year old woman with longstanding Atrial Fibrillation and heart failure treated with Warfarin, Ramipril 5mg daily and Bisoprolol 2.5mg daily. She complains of insomnia and falls. The hospital have prescribed Mirtazepine 30mg at night for significant depression.

A. Continue treatment
B. Stop the new drug prescribed
C. Stop an existing treatment

Answer: A

Assuming she is depressed, she may get better given time with mirtazepine. She requires careful cardiovascular assessment however – including postural blood pressures.

Theme – Prescribing for the Elderly

6. A 78 year old woman with longstanding hypertension consults you with marked ankle oedema. Her current medication is:- Ramipril 5mg daily; Amlodipine 5mg daily; Aspirin 75mg daily; Simvastatin 40mg daily and Lactulose 15ml at night. You can find no evidence of heart failure and her urine is negative. Her blood pressure is 140/78. Which one immediate intervention is most likely to help her?

A. Addition of Bendroflumethazide 5mg daily
B. Addition of Furosemide 40mg daily
C. Addition of Bumetamide 1mg daily
D. Stopping Amlodipine
E. Stopping Aspirin
F. Stopping Simvastatin

Answer: D

Stop Amlodipine. Despite its many benefits in this age group Amlodipine is a common cause of ankle oedema.

7. A 70 year old man presents to you as a new patient. He informs you that since a stroke two years ago he has suffered from dizziness and increasing difficulty mobilising. Initial recovery was good. His repeat prescriptions (from previous GP) are:- Ramipril 10mg daily; Indapamide 1.5mg daily; Aspirin 75mg daily; Atorvastatin 40mg daily; Furosemide 40mg daily; Prochlorperazine 5mg daily. Which focussed examinations below are most likely to lead to a management plan?

A. Cranial nerves and cerebellum
B. Mental state and reflexes
C. Muscle power and blood pressure
D. Postural blood pressure and gait
E. Pyramidal tracts and joint position sense

Answer: d

Postural blood pressure and gait. Regrettably this is not an uncommon scenario – inappropriate drug regimes find their way on to repeat prescribing systems (in this case a thiazide and loop diuretic which have synergistic actions) Consequences are treated symptomatically (in this case with a phenothiazine) which can itself cause Parkinsonism