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1 A Flumazenil is a benzodiazepine agonist 1 B Flumazenil is a benzodiazepine antagonist 1 C Benzodiazepines are commonly used anxiolytic drugs 1 D Benzodiazepines may be used in the treatment of epilepsy 1 E Carbamazepine is a benzodiazepine 7.2 Which of the following statements are correct? 1 A Lidocaine 0.2% with 1:80 000 adrenaline (epinephrine) is a commonly used dental local anaesthetic 1 B Lidocaine has a longer lasting anaesthetic effect than bupivacaine 1 C Plain lidocaine provides more pronounced dental anaesthesia than lidocaine with adrenaline 1 D Prilocaine 3% with 0.03 IU/ml felypressin is a commonly used dental local anaesthetic 1 E Lidocaine must be stored at 4 °C 7.3 Which of the following statements are correct? 1 A A 2.2 ml cartridge of 2% lidocaine and 1:80 000 adrenaline contains 4.4 mg of lidocaine 1 B Lidocaine and prilocaine contain an ester group 1 C Esters are less likely to cause allergic reactions than amides 1 D Amide local anaesthetics are metabolised by the liver 1 E Prilocaine has a much higher toxicity than lidocaine THERAPEUTICS 133 7.1 BCD Benzodiazepines are central nervous system depressants and act as sedatives, hypnotics, anxiolytics and anti-convulsants. Flumazenil is a benzodiazepine antagonist, commonly used to reverse the action of midazolam. Although having a name that sounds similar to benzodiazepine, carbamazepine is not a benzodiazepine. 7.2 D Lidocaine 2% with 1:80 000 adrenaline is a commonly used dental local anaesthetic. It has a more pronounced effect than lidocaine alone as adrenaline causes vasoconstriction, which prevents the solution dispersing away from the site of action. Bupivacaine is a longer lasting local anaesthetic than lidocaine. 7.3 D A 2% solution will contain 20 mg/ml, so a 2.2 ml cartridge contains 44 mg of lidocaine. Lidocaine and prilocaine contain an amide group, and as such are less likely to cause an allergic reaction than an ester-containing local anaesthetic. Lidocaine has higher toxicity than prilocaine.
134 MCQS FOR DENTISTRY 7.4 Which of the following drugs interact with warfarin and may increase a patient¶s international normalised ratio (INR)? 1 A Fluconazole 1 B Vitamin K 1 C Metronidazole 1 D Erythromycin 1 E Oral contraceptives 7.5 Non-steroidal anti-inflammatory drugs (NSAIDs) are best avoided in: 1 A Patients with a history of gastric bleeding 1 B Asthmatic patients 1 C Patients who are hypersensitive to aspirin 1 D Children under the age of 6 years due to the possibility of Reye¶s syndrome 1 E Patients on paracetamol 7.6 Penicillins: 1 A Are the antibiotic of choice for anaerobic infections 1 B Interfere with bacterial cell wall synthesis 1 C Are bacteriocidal 1 D Are antagonistic to tetracycline 1 E Rarely cause allergic reactions THERAPEUTICS 135 7.4 ACD Fluconazole, erythromycin and metronidazole may interact with warfarin and potentiate its action. The oral contraceptive pill and vitamin K may interact with warfarin, but they reduce its effect hence lowering the INR. 7.5 ABCD NSAIDs should be avoided in any patient with a history of hypersensitivity to aspirin or any other NSAID. They should also be avoided in patients with gastric/duodenal ulceration, and if it is necessary to prescribe them, then they should be given in conjunction with a selective inhibitor of cyclo-oxygenase±2 or gastroprotective treatment. Reye¶s syndrome can be caused by patients under the age of 16 years taking aspirin and hence it should be avoided in children. Patients on paracetamol can take NSAIDs as well as they have different modes of action and do not interact.
7.6 BCD The penicillins all act by interfering with bacterial cell wall synthesis, by inhibiting cross-linking of the mucopeptides in the cell wall and as such are bacteriocidal. Bacteria are attacked when cells are dividing and so in theory antibiotics that are bacteriostatic would decrease the efficacy of bacteriocidal drugs. However, this doesn¶t often cause a problem but tetracycline and penicillin are antagonistic and should not be used at the same time. Metronidazole is the antibiotic of choice for anaerobic infections. 136 MCQS FOR DENTISTRY 7.7 What are the appropriate drugs and dosages for use in the following emergencies? 1 A In suspected anaphylaxis ± 1:1000 adrenaline 0.5 ml intravenously 1 B In suspected anaphylaxis ± chlorphenamine 10 mg in 1 ml intramuscularly 1 C In a suspected angina attack ± glyceryl trinitrate intramuscularly 1 D In a suspected diabetic hypoglycaemic collapse where the patient is unconscious ± glucagon 10 mg intramuscularly 1 E In a suspected diabetic hypoglycaemic collapse where the patient is unconscious ± 50 ml of 20% glucose intravenously 7.8 Paracetamol is: 1 A Anti-pyretic 1 B Anti-inflammatory 1 C Locally acting 1 D Hepatotoxic in overdose 1 E Taken in doses of 500 mg ±1 g four times a day 7.9 Which of the following drugs and doses are commonly used in the treatment of atypical facial pain? 1 A Amitriptyline 10±25 mg daily 1 B Nortriptyline 10±25 mg daily 1 C Protirelin 10±25 mg daily 1 D Fluoxetine 20 mg daily 1 E Flumazenil 20 mg daily THERAPEUTICS 137 7.7 BE In suspected anaphylaxis 0.5 ml of 1:1000 adrenaline is given intramuscularly as is
chlorphenamine 10 mg in 1 ml (also intramuscularly). In an angina attack glyceryl trinitrate is usually administered sublingually. In a hypoglycaemic collapse glucagon 1 mg is given intramuscularly and/or 50 ml of 20% glucose intravenously. 7.8 ADE Paracetamol is a centrally acting analgesic with anti-pyretic properties. Unlike the NSAIDs it does not have anti-inflammatory properties. It is hepatotoxic in high doses. 7.9 ABD Amitriptyline and nortriptyline are both tricyclic antidepressants and are used in the treatment of atypical facial pain. Fluoxetine is a selective serotonin reuptake inhibitor and also used in the treatment of facial pain. Protirelin is a hypothalamicreleasing hormone which stimulates the release of thyrotrophin from the pituitary gland and so is not used for treatment of atypical facial pain. Flumazenil is a benzodiazepine antagonist used to reverse the central sedative effects of benzodiazepines. 138 MCQS FOR DENTISTRY 7.10 Which of the following are anti-fungal drugs? 1 A Miconazole 1 B Aciclovir 1 C Chlorhexidine 1 D Nystatin 1 E Itraconazole 7.11 Which of the following must always be included in a prescription? 1 A The name and address of the prescriber 1 B The age of the patient 1 C The date of prescription 1 D The dose of the drug in numbers and words 1 E The address of the patient 7.12 Which of the following drug doses and concentrations are correct for using in an anaphylactic reaction? 1 A Adrenaline 0.5 ml of 1:100 intramuscularly 1 B Adrenaline 0.5 ml of 1:1000 intramuscularly 1 C Hydrocortisone sodium succinate 2 mg intravenously 1 D Hydrocortisone sodium succinate 20 mg intravenously 1 E Hydrocortisone sodium succinate 200 mg intravenously
THERAPEUTICS 139 7.10 ADE Miconazole is an imidazole anti-fungal drug, Nystatin is a polyene anti-fungal drug and itraconazole is a triazole anti-fungal. Aciclovir is an anti-viral drug and chlorhexidine is an antiseptic. 7.11 ACE The name and address of the prescriber, the date of prescription and the address of the patient must be included. It is desirable to include the age and date of birth of the patient, but this is a legal requirement for only prescription-only medicines for patients under 12 years of age. The drug dose only needs to be put in words and figures if it is a controlled drug. 7.12 BE Appropriate treatment of a suspected anaphylactic attack involves 0.5±1 ml of a 1:1000 solution of adrenaline administered intramuscularly. Hydrocortisone sodium succinate 200 mg intravenously should also be given. 140 MCQS FOR DENTISTRY
Three examples of SBAs taken from the three clinical areas outlined above now follow. A. Clinical Anaesthesia A previously fit 78 year-old man has a transurethral resection of the prostate (TURP) performed under general anaesthesia taking 90 minutes to complete. Half an hour after arrival in the recovery room he has not regained consciousness. Respiratory effort is adequate and vital signs are stable. Which of the following deranged investigations is most likely to account for his current clinical condition? A. Haemoglobin 7.1 g/dl B. Serum sodium 114 mmol/L C. Serum glucose 2.8 mmol/L ANSWER = B D. PaO2 8.9 kPa (FiO2 = 0.35) E. PaCO2 7.4 kPa B. Intensive Care Medicine A 75 year-old man is admitted to HDU following an episode of severe chest pain and collapse with transient loss of consciousness. On admission he is conscious and complaining of chest pain radiating into his back. Blood pressure measured in the right
arm is 210/110. The left radial pulse is absent and there are signs of a left hemiparesis. Which one of the following is the most likely diagnosis? A. Acute pulmonary embolism B. Acute myocardial infarction with systemic embolisation. C. Dissecting aneurysm of the thoracic aorta D. Acute rupture of the aortic valve ANSWER = C E. Rupture of a mycotic aneurysm of the aortic arch C. Pain Management A previously fit 5-year-old girl is distressed and in severe pain in the recovery room following emergency appendicectomy. She is awake and cardiovascularly stable. Intraoperatively, she received fentanyl 2 mcg kg-1 iv, paracetamol 15 mg kg-1 iv & dicloflenac 1mg kg-1 PR. What would be the most appropriate analgesia option for her now? A. Adminster Entonox until the child calms down B. Codeine phosphate 1 mg kg-1 orally C. Codeine phosphate 1 mg kg-1 intramuscularly ANSWER= E D. An intravenous morphine infusion at 10 mcg kg-1 hour-1 E. Morphine 0.1 mg kg-1 intravenous bolus
1. In respiratory alkalosis: a) cerebral arterioles constrict b) the oxygen dissociation curve is shifted to the right c) the concentration of ionised calcium increases d) there is an increased risk of fits 2. The following are true of local anaesthetic nerve blocks: a) Femoral nerve block may cause paraesthesia over the medial aspect of the calf and the medial malleolus b) Infiltration of local anaesthetic 1cm to the ulnar side of the palmaris longus tendon at the wrist will reliably produce a median nerve block c) Infraorbital nerve block commonly results in adequate anaesthesia for suturing of upper lip lacerations d) Anaesthesia of the pinna can be obtained by blockade of the great auricular
nerve immediately anterior to the tragus 3. Acute dystonic reactions may occur following oral administration of: a) Prochlorperazine b) Diazepam c) Metoclopramide d) Haloperidol 4. The following substances increase insulin resistance: a) Cortisol b) Prolactin c) Growth hormone d) Endogenous adrenaline 5. The following infections are shown to be a transfer risk from needlestick injuries: a) Hepatitis E b) Plasmodium falciparum c) Syphilis d) Leptospirosis