1. A 60-year-old man with a history of hypertension presents with bradycardia (heart rate 42 bpm) and hypotension. He recently increased his atenolol dose. What is the most appropriate initial management?

• Administer IV atropine
• Discontinue atenolol and monitor
• Start glucagon infusion
• Initiate transcutaneous pacing

Answer: Administer IV atropine

IV atropine is the first-line therapy for acute symptomatic bradycardia, including beta-blocker-induced bradycardia. If ineffective, glucagon or pacing may be considered.

2. A 55-year-old man taking atorvastatin for hyperlipidaemia reports muscle pain and weakness. What is the most appropriate next step?

• Stop atorvastatin and check creatine kinase levels
• Reduce the dose of atorvastatin
• Switch to a fibrate
• Add coenzyme Q10 supplementation

Answer: Stop atorvastatin and check creatine kinase levels

In patients on statins who develop muscle symptoms, statin-induced myopathy must be ruled out by discontinuing therapy and checking CK levels.

3. A 30-year-old woman with Crohn’s disease is started on azathioprine. What test is essential before initiating treatment?

• Thiopurine methyltransferase (TPMT) activity
• Full blood count and liver function tests
• HIV serology
• Vitamin D levels

Answer: Thiopurine methyltransferase (TPMT) activity

Measuring TPMT activity identifies patients at high risk of azathioprine-induced bone marrow suppression, allowing dose adjustments or alternative therapy.

4. A 25-year-old woman using a beclometasone inhaler for asthma asks how to prevent oral thrush. What is the correct advice?

• Rinse the mouth after using the inhaler
• Use a spacer device
• Switch to oral corticosteroids
• Reduce the frequency of inhaler use

Answer: Rinse the mouth after using the inhaler

To prevent oral candidiasis from inhaled corticosteroids, patients should rinse their mouth or brush their teeth after each use.

5. How does bendroflumethiazide lower blood pressure?

• Inhibition of sodium reabsorption in the distal tubule
• Inhibition of sodium-potassium ATPase pump in the proximal tubule
• Blocking aldosterone receptors in the collecting ducts
• Inhibition of carbonic anhydrase in the proximal tubule

Answer: Inhibition of sodium reabsorption in the distal tubule

Bendroflumethiazide is a thiazide diuretic that reduces sodium reabsorption in the distal convoluted tubule, lowering plasma volume and BP.

6. In which condition is bisoprolol most beneficial for improving long-term prognosis?

• Stable angina
• Heart failure with reduced ejection fraction
• Hypertension
• Atrial fibrillation rate control

Answer: Heart failure with reduced ejection fraction

Bisoprolol (and certain other beta-blockers) is proven to reduce mortality in HFrEF, while in other conditions it mainly provides symptomatic benefit.

7. A 40-year-old man with Crohn’s disease declines budesonide treatment despite being counselled about its benefits. What is the most appropriate next step?

• Respect his decision and document the discussion
• Prescribe the medication regardless of his decision
• Refer him to a specialist for further counselling
• Withhold all treatment until he agrees

Answer: Respect his decision and document the discussion

Patient autonomy must be respected if they have capacity. Document the discussion and continue to offer supportive care.

8. What is the mechanism of action of buprenorphine?

• Full agonist at opioid receptors
• Partial agonist at mu-opioid receptors
• Antagonist at opioid receptors
• Inhibitor of norepinephrine reuptake

Answer: Partial agonist at mu-opioid receptors

Buprenorphine’s partial mu-agonist action provides analgesia with a lower risk of respiratory depression compared to full agonists.

9. A 30-year-old man overdoses on carbamazepine. He presents with drowsiness, ataxia, and arrhythmias. What is the most appropriate initial management?

• Activated charcoal if within 1 hour of ingestion
• Administer flumazenil
• Start IV naloxone
• Perform gastric lavage immediately

Answer: Activated charcoal if within 1 hour of ingestion

Early administration of activated charcoal can reduce carbamazepine absorption. Supportive measures may be required for severe toxicity.

10. What is the most serious side effect of carbimazole?

• Hepatotoxicity
• Agranulocytosis
• Hypothyroidism
• Rash

Answer: Agranulocytosis

Carbimazole can rarely cause agranulocytosis, leading to severe infections. Patients should report any sore throat or fever urgently.