Contraindications - and how they trip people up
Feb 08, 2025
Have a look at this question:
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Jazmin Richards, 37 years old, complains of frequent and long standing unilateral throbbing headaches occurring four times a week and which are disrupting her work-related duties. She has a past medical history of Raynaud’s phenomenon. On examination, her vital signs and physical examination is unremarkable. Her body mass index is 37.2kg/m2. A magnetic resonance imaging scan of her brain six months ago shows a 1cm incidental cavernous cyst.
What is the most appropriate next step?
A. Digital subtraction angiogram
B. Pizotifen 500mcg orally once daily
C. Propranolol 40 mg orally once daily
D. Topiramate 25 mg orally once daily (Score:1)
E. Refer to neurosurgeon
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What did you think of it? You probably thought "pretty straightfoward" - but what if you were in the middle of an exam scenario, stressed and running out of time? How easy would it have been to answer Options B or C? In case you missed it, our patient has Raynaud's which renders a beta blocker relatively contraindicated. She is also obese, which is not ideal with pizotifen given its association with weight gain.
Adding contraindications to a question is one of the oldest tricks in the exam bank. But why? In many places, examiners are paid on a fee-per-question basis - no question = no payment. Often when examiners submit their questions, they are told by the reviewing committee to make them harder. Adding a contraindication is a very quick way to resubmit the question, make it harder, and in doing so to get paid for your work.
As such, these are very common, and very easy to miss. As such make it a routine to check each question for a contraindication.
Be especially weary if you see a question with these drugs in:
-an oral contraceptive pill
-beta blockers
-NSAIDs
-oral bisphosphonate (risk of oesophageal irritation
-menopausal hormonal therapy
These drugs have multiple contraindications, which makes them very prone to a question being manipulated to feature a contraindication. As such, expect to see this in both clinical and MCQ exams.
