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INTERNSHIP > 05 July > Flashcards

05 July Flashcards

1
Q 
PHARMACIST HANDOVER:
PC: R lower leg infection/pain/swelling- venous / ? arterial component
PROCEDURES:
PLAN:
Arterial Ix
PMHx:
# CVA 1992 - Haemorrhagic
# Right lower limb DVT 10 years ago
# Chronic right lower limb oedema/ulcers
# HTN
# Depression
#R VV stripping ~ 20 years ago
.
CHECKLIST:
NOT FOR DVT Px give haemorrhagic stroke history
# Tazo / vanc
21/6 swab: +++GNB/GPB
No antiplatelet/statin- haem stroke

Deficiencies: CHASE

Background:

Presenting Complaint: 74-year-old lady newly living alone, previously lived with daughter.

Current Issues: 
# Right leg cellulitis
- Treated with IV tazocin/vancomycin
- MRSA positive on 21/6
- For 10 days doxycycline (completes 6/7)

PC: Presents with worsening pain, erythema, swelling and exudate R lower leg /foot
Chronic right leg DVT not treated due to haemorrhagic stroke.
# 24/06 - ?Cold sepsis, ?Septic Arthritis

# CVA 1992 - Haemorrhagic
- Right sided residual hemiplegia
- Contractures of right hand and foot
# Right lower limb DVT 10 years ago
# Chronic right lower limb oedema with chronic ulcers
- Previous MRSA sensitive to vanc, doxy and clotrimazole
# HTN
# Depression
# R VV stripping ~ 20 years ago

Pharmacy to notify community pharmacy of any changes to packed medications prior to discharge.

A

TBC

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2
Q

Team to review list of medicines above, chart regular medications as clinically appropriate.
Issues for review:
ID code require for ongoing vancomycin. 2g stat dosing appropriate given patient weight. Ongoing 1g BD appropriate given weight and calculated CrCl of 42ml/min Vancomycin trough due tomorrow morning, prior to 4am dosing.
Noted that oxycodone held for sedation, can now likely be recommenced at lower dosing to avoid sedation. Given analgesic requirement - team to consider charting paracetamol regularly.
Team to review when irbesartan to be restarted (was held due to trimethoprim/ sulfamethoxazole course, now completed).
Team to review Baclofen dosing - ?intentionally increased to BD.
Micronutrients: NAD vitamin D, selenium and zinc. Nil vitamin C, A and E - team to consider another screen for evaluation.

A

TBC

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3
Q

Presenting Complaint:
Presents with worsening pain, erythema, swelling and exudate R lower leg /foot
Chronic right leg DVT not treated due to haemorrhagic stroke.
# 24/06 - ?Cold sepsis, ?Septic Arthritis

Current Issues: 
# Right leg cellulitis
- Treated with IV tazocin/vancomycin
- MRSA positive on 21/6
- For 10 days doxycycline (completes 6/7)
A

tbc

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4
Q

VTE PROPHYLAXIS:
29/06: enoxaparin 40 mg subCUTANEOUS every NIGHT

REGULAR MEDICATIONS NOT CHARTED:
[ ] paracetamol - codeine 500mg-30mg 1 to 2 tablets oral every SIX hours PRN (standard paracetamol charted)
[ ] trimETHROPRIM - sulfamethoxazole 160mg-800mg 1 tabelt oral TWICE daily with food

NEW MEDICATIONS:
20/06: paracetamol 1 g oral every FOUR hours PRN
21/06: docusate sodium - sennoside B 50mg-8mg 2 tablets oral TWICE daily
21/06: ondansetron injection 4 to 8 mg intravenous THREE times daily PRN
23/06 naloxone as per APS protocol
29/06: doxycycline 100 mg oral TWICE daily with food (due to complete course on 06 July)
02/07: oxycodone hydrochloride 1.25 to 2.5 mg oral every FOUR hours PRN (started on 5 to 10 mg oral every FOUR hours PRN on 20/06)
05/07: ascorbic acid chewable tablet 1000 mg oral every MORNING

DOSE REDUCTION:
24/06: baclofen 10 mg oral every NIGHT with food (was on 20 mg oral every NIGHT at home)

UNCHANGED MEDICATIONS:
# calcium carbonate - colecalciferol 1.5g-12.5microgram one tablet oral every NIGHT 
# desvenlafaxine controlled release tablet 100 mg oral every MORNING 
# furosemide 40 mg oral every MORNING 
# gabapentin 300 mg oral THREE times daily 
# irbesartan 150 mg oral every MORNING 
# magnesium aspartate 500 mg 1 tablet oral every MORNING with food 
# nortriptyline 10 mg oral every NIGHT
A

tbc

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5
Q

VTE PROPHYLAXIS:
29/06: enoxaparin 40 mg subCUTANEOUS every NIGHT

REGULAR MEDICATIONS NOT CHARTED:
[ ] paracetamol - codeine 500mg-30mg 1 to 2 tablets oral every SIX hours PRN (standard paracetamol charted)
[ ] trimETHROPRIM - sulfamethoxazole 160mg-800mg 1 tabelt oral TWICE daily with food

NEW MEDICATIONS:
20/06: paracetamol 1 g oral every FOUR hours PRN
21/06: docusate sodium - sennoside B 50mg-8mg 2 tablets oral TWICE daily
21/06: ondansetron injection 4 to 8 mg intravenous THREE times daily PRN
23/06 naloxone as per APS protocol
29/06: doxycycline 100 mg oral TWICE daily with food (due to complete course on 06 July)
02/07: oxycodone hydrochloride 1.25 to 2.5 mg oral every FOUR hours PRN (started on 5 to 10 mg oral every FOUR hours PRN on 20/06)
05/07: ascorbic acid chewable tablet 1000 mg oral every MORNING

DOSE REDUCTION:
24/06: baclofen 10 mg oral every NIGHT with food (was on 20 mg oral every NIGHT at home)

UNCHANGED MEDICATIONS:
# calcium carbonate - colecalciferol 1.5g-12.5microgram one tablet oral every NIGHT 
# desvenlafaxine controlled release tablet 100 mg oral every MORNING 
# furosemide 40 mg oral every MORNING 
# gabapentin 300 mg oral THREE times daily 
# irbesartan 150 mg oral every MORNING 
# magnesium aspartate 500 mg 1 tablet oral every MORNING with food 
# nortriptyline 10 mg oral every NIGHT
A

TBC

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6
Q 
PHARMACIST HANDOVER:
PC: R lower leg infection/pain/swelling- venous / ? arterial component
PROCEDURES:
PLAN:
Arterial Ix
PMHx:
# CVA 1992 - Haemorrhagic
# Right lower limb DVT 10 years ago
# Chronic right lower limb oedema/ulcers
# HTN
# Depression
#R VV stripping ~ 20 years ago
.
CHECKLIST:
NOT FOR DVT Px give haemorrhagic stroke history
# Tazo / vanc
21/6 swab: +++GNB/GPB
No antiplatelet/statin- haem stroke

Deficiencies: CHASE

Current Issues: 
# Right leg cellulitis
- Treated with IV tazocin/vancomycin
- MRSA positive on 21/6
- For 10 days doxycycline (completes 6/7)

PC: Presents with worsening pain, erythema, swelling and exudate R lower leg /foot
Chronic right leg DVT not treated due to haemorrhagic stroke.
# 24/06 - ?Cold sepsis, ?Septic Arthritis

# CVA 1992 - Haemorrhagic
- Right sided residual hemiplegia
- Contractures of right hand and foot
# Right lower limb DVT 10 years ago
# Chronic right lower limb oedema with chronic ulcers
- Previous MRSA sensitive to vanc, doxy and clotrimazole
# HTN
# Depression
# R VV stripping ~ 20 years ago

Pharmacy to notify community pharmacy of any changes to packed medications prior to discharge.

BLOOD PRESSURE:
05/07: 119/53 mmHg –> team please monitor

BOWELS:
05/07: BNO as per patient –> NS please monitor

REGULAR MEDICATIONS NOT CHARTED:
[ ] paracetamol - codeine 500mg-30mg 1 to 2 tablets oral every SIX hours PRN (standard paracetamol charted)
[ ] trimETHROPRIM - sulfamethoxazole 160mg-800mg 1 tabelt oral TWICE daily with food

NEW MEDICATIONS:
20/06: paracetamol 1 g oral every FOUR hours PRN
21/06: docusate sodium - sennoside B 50mg-8mg 2 tablets oral TWICE daily
21/06: ondansetron injection 4 to 8 mg intravenous THREE times daily PRN
23/06 naloxone as per APS protocol
29/06: doxycycline 100 mg oral TWICE daily with food (due to complete course on 06 July)
02/07: oxycodone hydrochloride 1.25 to 2.5 mg oral every FOUR hours PRN (started on 5 to 10 mg oral every FOUR hours PRN on 20/06)
05/07: ascorbic acid chewable tablet 1000 mg oral every MORNING

DOSE REDUCTION:
24/06: baclofen 10 mg oral every NIGHT with food (was on 20 mg oral every NIGHT at home)

Monitor for hypotension given baclofen and several antihypertensives are charted.
Check doxycycline and calcium are not being given at the same time.
No ondansetron given this week - suggest removing from chart
Paracetamol not being given but oxycodone is - suggest charting regular paracetamol to optimise paracetamol effect and using oxycodone PRN for breakthrough pain.
Micronutrients: NAD vitamin D, selenium and zinc. Nil vitamin C, A and E - team to consider another screen for evaluation.

A

TBC

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7
Q

What does Ix stand for?

A

Investigations

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8
Q

What does VV stand for?

A

Varicose vein

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9
Q

Cerebral amyloid angiopathy (CAA)

A

TBC

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10
Q 
Micronutrient Screen for Wound Healing: 
Zinc            ###       LOW/HIGH
Selenium   ###       LOW/HIGH
D                 ###       LOW/HIGH
C                 ###       LOW/HIGH
A                 ###       LOW/HIGH
E                  ###       LOW/HIGH
A

TBC

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11
Q

Why are albumin levels important with warfarin?

A

TBC

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12
Q

Mesenteric ischaemia

A

TBC

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13
Q

Mesenteric ischaemia with multiorgan failure

  • Laparotomy (05/05) SBO, internal left paraduodenal hernia, purulent peritonitis -> division of adhesions + wash out & VAC dressing
  • Laparotomy (06/05) patchy terminal ileal & distal transverse colon, descending colon and sigmoid ischaemia with further areas of ischaemia developing throughout operation -> total colectomy + ileal resection & VAC dressing
    Felt that ischaemic bowel was secondary to acidosis, hypotension, sepsis and ?inotropes
  • Laparotomy (10/05) Resection of gangrenous bowel & creation of ileostomy
  • antimicrobial - previously received vancomycin/ metronidazole/ ceftriaxone (5-6/5), Tazocin 6/5 - 20/5
    # Anuric renal failure - likely ATN in context of significant prerenal insult/ shock/ sepsis after extensive bowel surgery for ischaemic bowel
  • baseline creat 61 (5/5/22)
  • dialysis dependent
  • No dedicated renal imaging however CT Abdo (13/5) no hydronephrosis, multiple renal cysts.
  • permacath inserted 17/5/22; last EDD 21/5
    ANA positive, speckled, 1:160
    -ENA/ANCA/DsDNA normal
    -Complements elevated, Hep b surface antigen negative, Hep c NAT negative
    -Anti GBM/serum paraprotein normal, SFLC ratio normal
    -Rash on arms,?impetigo,seen by Derm, on cefalexin, improving
    -Albumin 20, ACR 15.1
    -Cryoglobulins pending
    -MAG 3 scan c/w ATN
# Ischaemic hepatitis with possible ischaemic infarct on CT
# Fluctuating neurology - Hypoxic delirium in ICCU - resolved 
- MRI Brain nil acute/ evidence of hypoxic injury
# Grade 2 sacral ulcer
# Deconditioning
A

tbc`

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14
Q 
T2DM - oral medications - SGLT2 inhibitor
BPH
HTN
GORD
Sphincterotomy 
Scheuermanns diseaese
Bilat hernia repair 
Nephrolithiasis 
BPH
Depression
A

TBC

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15
Q

VaxiGrip Tetra

A

TBC

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16
Q

VTE PROPHYLAXIS:
11/05: heparin sodium injection 5000 units subcutaneous TWICE daily

REGULAR MEDICATIONS NOT CHARTED:
[ ] aspirin 100 mg oral every NIGHT with food
[ ] atorvastatin 40 mg oral every NIGHT
[ ] candesartan cilexetil 32 mg oral every NIGHT
[ ] celecoxib 200 mg oral every NIGHT
[ ] diltiazem hydrochloride controlled release capsule 360 mg oral every NIGHT
[ ] moxonidine 200 microgram oral every MORNING
[ ] moxonidine 400 microgram oral every NIGHT
# RABEprazole sodium enteric coated tablet 20 mg oral every NIGHT (replaced with omeprazole magnesium enteric coated dispersible tablet as RABEprazole is not stocked at FMC)

NEW MEDICATIONS:
21/05: sliding scale insulin aspart
29/05: naloxone as per APS protocol.
31/05: urea 10% cream 1 application topical every NIGHT
07/06: triclosan 1% body wash 1 application topical TWICE a WEEK on WEDNESDAY and SATURDAY in the MORNING
09/06: mometasone furoate 0.1% lotion 1 application topical TWICE daily
10/06: omeprazole magnesium enteric coated dispersible tablet 20 mg oral every MORNING
15/06: paracetamol 1000 mg oral FOUR times daily PRN
21/06: benzydamine hydrochloride - cetylpyridinium chloride 3mg-1.33mg (DIFFLAM) lozenge 1 lozenge oromucosal every FOUR hours PRN
21/06: hyoscine butylbromide 10 mg oral THREE times daily PRN
21/06: nystatin 100,000units/mL oral liquid 100,000 units/mL oral liquid 1 mL oral FOUR times daily
21/06: oxycodone hydrochloride 5 mg oral every EIGHT hours PRN
30/06: magnesium aspartate 500 mg oral TWICE daily with food
03/07: sodium citrate - sodium lauryl sulfoacetate - sorbitol 450mg-45mg-3.125g enema 1 to 2 enema(s) rectal every 24 hours PRN
04/07: insulin glargine 10 units subcutaneous every NIGHT (originally started on 30 units subcutaneous every 24 hours on 13/05)

UNCHANGED MEDICATIONS:
# PARoxetine 40 mg oral every MORNING with food

HELD MEDICATIONS:
28/05: furosemide injection 80 mg TWICE daily

A

TBC

17
Q

tenesmus

A

TBC

INTERNSHIP (189 decks)

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