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DIPLOMA > 18 month exam revision > Flashcards

18 month exam revision Flashcards

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1
Q

In patients with ACS, we are looking for raised troponin levels to aid diagnosis. What other conditions could raise troponin?

A

AF

Poor Renal Function

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2
Q

Drug eluting stents contain antiproliferative agents such as _____ to stop cells growing around the stent

A

Paclitaxel

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3
Q

What is referred to as high dose ICS in terms of BDP equivalence?

A

1,200–2,000 micrograms per day in 2 divided doses of Beclomethasone Dipropionate

Budesonide: 1,000–1,600 micrograms per day in 2 divided doses

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4
Q

When critically appraising a randomised control trial using the CASP tool, what is most important to consider?

A

Whether the results are statistically significant

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5
Q

What is paroxysmal AF as per NICE?

A

Paroxysmal atrial fibrillation spontaneously terminates within 7 days, usually within 48 hours

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6
Q

Which of the following side effects of amiodarone is listed as common?

Nausea + vomitting
Liver toxicity
Thyroid disorders
Corneal microdeposits

A

Thyroid disorders

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7
Q

In a patient with severe hyperkalemia (K+ of 6.6 & ECG changes present), what is the primary focus for management?

A

In patients with severe hyperkalemia, treatment focuses on immediate stabilization of the heart using calcium gluconate:

10–20 mL, calcium gluconate 10% over 3-5 minutes

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8
Q

What is the mechanism of action of Aminoglycosides?

A

bind to the 30s ribosomal sub-unit and inhibit protein synthesis

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9
Q

Patients with CAP and a CURB score of 3-5 are classed as having severe pneumonia. What treatment is indicated here?

A

IV treatment
Co-amoxiclav 1.2 g tds IV plus
clarithromycin 500 mg bd IV

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10
Q

Patients classed as having moderate severity CAP (CURB score = 2) are treated how?

A

Amoxicillin 500 mg – 1.0g tds orally plus clarithromycin 500 mg bd orally

alternative: Doxycycline 200 mg loading dose then 100 mg

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11
Q

Rash is considered a Type __ reaction to Phenytoin

A

Type B

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12
Q

What are the risks with NG tubes? state two potential risks

A

Infection risk

Dislodging/ aspiration

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13
Q

What happens with grade 4 (severe) hypovolaemic shock?

A

> 2L of fluids lost

Severe hypotension

Anuria (no unrine output)

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14
Q

Being female and a non-smoker puts you more at risk of what condition?

A

Post operative nausea and vomitting

These two factors along with history or PONV & post-op opioid administration are all factors in the Apfel scoring system for PONV.
If any opioid is used during surgery, patients are considered high risk

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15
Q

Gynae, abdominal, ear/ ENT surgery all pose a greater risk of what?

A

Post op nausea and vomitting

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16
Q

What was the name of the case-control study that found 10 different risk factors to account for 90% of strokes?

A

INTERSTROKE

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17
Q

Alteplase is proven to significantly reduce death and disability at 90 days.
What is the time window in which Alteplase can be administered? The ISHT-3 trial showed similar efficacy if Alteplase is administered to those under 80 years old and also over 80 (showed to be safe). It showed that greatest benefit is seen if Alteplase is administered within __ hours.

A

Should be administered within 4.5 hours

Greatest benefit if administered within 3 hours

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18
Q

What does the ABCD(^2) tool show?

A

It estimates the risk of recurrence of stroke at 2 days and 7 days post TIA. Those with scores of over 5 are at 10x greater of having a recurrent stroke than those with scores under 4. Those with scores of >4 should have a same day assessment in the stroke unit (within 24 hours)

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19
Q

What trial supports the use of Aspirin 300mg OD for 2 weeks post stroke?

A

CAST

IST

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20
Q

What trial supports the use of Aspirin to Clopidogrel switch after 14 days post stroke?

A

PROFESS

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21
Q

What type of lipoproteins should be reduced in patients with ischaemic stroke or TIA caused by athersclerosis?

A

Low density Lipoprotein cholesterol

Target LDL: <2mmol/L

Reducing LDL level by 1mmol/L reduces risk of recurrent stroke by 12% and all strokes by 21%
Reducing LDL level by 2-3mmol/L reduces risk of stroke by 40-50%

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22
Q

What statin/ dose should be considered for patients with TIA or ischeamic stroke?

A

Atorvastatin 80mg

THIS IS SECONDARY PREVENTION

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23
Q

If patients are intolerant to aspirin, then clopidogrel 300mg OD can be used for 14 days post stroke then 75mg OD thereafter

Which Trials support this?

A

CARESS

CAPRIE

PROFESS

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24
Q

What did the stroke trial ‘INTERACT 2’ show?

A

ANTIHYPERTENSIVES TRIAL:
In patients with intracerebral heamorrhage, intensive lowering of blood pressure did not result in a significant reduction in the rate of death or severe disability

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25
Q

The PROGRESS Trial involved
Preventing Strokes by Lowering Blood Pressure in Patients with Cerebral Ischemia.

What was the first line ACEi used in this trial?It was shown to be effective in combination with which diuretic to lower BP?

A

Perindopril

In combo with Indapamide

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26
Q

Why should we hold of antihypertensives in the acute phase of stroke?

A

IF the clot is still in place, only a tiny amount of blood will be getting through, therefore we dont want to hypoperfuse the brain even further

Can consider starting statins/ BP meds 48 hours after symptom onset/ initial treatment and after imaging confirms clot has gone.

Megans notes: after 10 - 14 days antihypertensive treatment can be started if BP greater than 140/85

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27
Q

What is target BP post TIA?

What class of medicines should be avoided to assist in lowering BP post stroke?

A

under 130/80

Avoid use of beta blockers

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28
Q

Diltiazem is often seen used in patients with persistent / permanent AF. What type of drug is this?

Why should this never be used in combo with a beta blocker?

A

Rate limiting calcium channel blocker
Other rate limiting CCB: Verapamil

Beta blocker + Diltiazem/ Verapamil= potential to cause heart block if used together

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29
Q

What is the difference between Paroxysmal, Permanent and Persistent AF?

A

Paroxysmal: This is an episode of atrial fibrillation that lasts less than a week, usually resolves within 48 hours
Commonly manages with ‘Pill in the pocket’- Flecainide, sotolol, amiodarone

Persistent: Usually, this lasts longer than a week
Permanent: AF symptoms that do not go away

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30
Q

What levels of BP are classified as STAGE 1, 2, and 3 hypertension?

A

1: BP= 140/90mmHg and above
2: BP= 160/100mmHg and above
3: BP= 180/ 110mmHg and above

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31
Q

Do we ever combine both an ACE inhibitor plus an ARB to control hypertension?

A

NO- its only either or used

Black afro-carribean: consider using an ARB at step 2 over ACE inhibitor treatment (use a CCB first line)

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32
Q

What are the preferred diuretics of choice used for Hypertension?

A

Thiazide like diuretics

Namely Indapamide or Chlortalidone

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33
Q

Why are beta blockers contra-indicated in patients with diabetes?

A

As they may block signs of low blood sugar, such as rapid heartbeat

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34
Q

What is the name of the assessment tool to assess Cardiovascular Disease Risk (CVD risk) for the primary prevention of CVD in people up to 84 years old?

This tool estimates the risk of a CV event occuring in the next ___ years.

A

QRISK2

Estimates the risk of a CVD event happening in the next 10 years

35
Q

What is the difference between Type A and Type B adverse drug reactions?

A

Type A are predictable, dose-related toxicities, often identified in preclinical or clinical trials, and usually occur in overdose settings or with pre-existing hepatic impairment- e.g. respiratory depression with opioids

Type B are not clearly related to increasing dose and are associated with drug-specific and patient-specific characteristics. Hypersensitivity (allergic) reactions to drugs are examples of type B ADRs- e.g. rash/ anaphylaxis with penicillins

36
Q

Which cholesterol (HDL/ non-HDL/ LDL) is the bad stuff?

A

HDL= GOOD cholesterol

non HDL/ LDL= BAD cholesterol. Statin therapy aims to reduce this level

Non HDL(bad) = Total Cholesterol minus HDL (good) cholesterol

37
Q

What level of statin therapy should be used for patients with a 10% or greater 10-year risk of developing CVD? Should this be used first line?

A

Atorvastatin 20mg

PRIMARY PREVENTION

Advice on lifestyle changes should be used first line
Statin therapy should be second line

38
Q

What organ may statins affect and therefore what should be monitored?

A

Liver

LFT’s - baseline, 3 months, 12 months

39
Q

In patients with T1DM, when should statins be used?

A

Primary prevention (atorvastatin 20mg) should be used in patients with type 1 diabetes who are:

Over 40 years old
Had diabetes for >10 years
Have established nephropathy
Have other CVD risk factors

40
Q

Adults newly diagnosed with CVD are offered atorvastatin at what dose?

A

atorvastatin 80mg

41
Q

What is the name of the trial that showed the role of Spironolactone to improve mortality in patients with HF?

A

RALES trial

Spironolactone at a dose of 25mg on alternate days, increased to 50mg OD if tolerated

It is an aldosterone antagonist, it should be administered within 3-14 days of a Heart Attack, preferably after an ACEi has been started

42
Q

In patients with Heart Failure, what drug combination is a suitable alternative to an ACE inhibitor and an ARB for those that are intolerant?

A

Hydrazaline in combination with a nitrate!!!

43
Q

When should Digoxin be used in patients with HF?

A

Used for worsening or severe Heart Failure due to LVSD despite first or second line Tx

44
Q

When should patients undergoing surgery have their warfarin stopped?

A

All patients requiring surgery should have their warfarin stopped 5 days before the operation

Give phytomenadione (po VitK) day before if INR ≥ 1.5

45
Q

Patients on warfarin need their therapy bridging if undergoing surgery. We tell them to stop taking warfarin 4 days before treatment

How do we bridge patients deemed low risk?

How do we bridge patients deemed intermediate risk?

A

Low risk: no bridging required

Intermediate Risk- Bridge with PROPHYLACTIC enoxaparin 3 days pre-operatively at 9.00am. Miss on the morning of surgery and resume 6 hours post-operatively until patient reaches and INR of 2

46
Q

Patients on warfarin need their therapy bridging if undergoing surgery. We tell them to stop taking warfarin 4 days before treatment

How do we bridge patients deemed highrisk?

A

High Risk- Bridge with TREATMENT dose enoxaparin at 9am 3 days pre-operatively, miss on the morning of the operation and resume 6 to 24 hours post-op once haemostasis is secure until the patient reaches an INR of 2.

47
Q

When should we consider stopping oestrogen containing oral contraceptives/HRT before surgery due to increased clot risk?

A

Consider stopping oestrogen containing oral contraceptives/HRT 4 weeks before elective surgery with alternative contraception

48
Q

Anesthetics carry a risk of VTE/DVT.

What carries increased risk?

A

General over Local anaesthetic

Surgical Procedure with a total anaesthetic and surgical time >90 minutes, or 60 minutes if surgery involves the pelvis or lower limb

49
Q

VTE prophylaxis recommended for __ weeks following:

Total Hip Replacement?

Total Knee Replacement?

Fractured neck of femur (#NOF)?

A

Total Hip Replacement and #NOF= 4-5 weeks

Total Knee Replacement= 2 weeks

50
Q

What is DKA?

A

Insulin deficiency results in ketone production in the liver.

Ketones are excreted by the kidneys and are initially buffered in the blood, however once the system fails then metabolic acidosis occurs.

51
Q

How should patients on sulphonylureas undergoing LONG surgeries be managed?

A

Pre-surgery intervention is not usually required for short-medium surgery

For longer surgeries, short-acting sulphonylureas (gliclazide and tolbutamide) should be omitted on the morning of the surgery to reduce the risk of hypoglycaemia that can occur in the NBM patient.

Longer-acting sulphonylureas (e.g. glibenclamide) should be stopped two to three days before surgery and can be converted to either short-acting sulphonylureas or insulin.

52
Q

How is metformin manged pre-surgery?

A

For longer surgeries or surgeries using contrast media metformin should be stopped 48 hours before surgery with general anaesthesia

It should not be started for at least 48 hours after to reduce the risk of lactic acidosis

53
Q

What is the GLIK regimen?

A

GLIK is basically insulin administered as a single dose as an infusion with glucose and potassium

Suitable for patients likely to be NBM for <48 hours

It is not as flexible as a sliding scale, but is easy to control on a busy surgical ward

Sliding scale is more appropriate if NBM >48 hours, its more titratable and provides more stable blood glucose levels

54
Q

At what level eGFR should metformin be re-commenced after surgery?

A

Metformin should only be recommenced if the eGFR is > 50mls/min

(Contra-indicated if eGFR <45)

55
Q

Can you think of three SICK DAY rules for diabetic patients?

A

Never stop taking insulin or tablets- illness increases your need for insulin

Test blood glucose levels every 2 hours, day and night

Test urine for ketones every 2 hours

Eat normally + stay hydrated

56
Q

How is an intravenous aminophylline dose converted to an oral aminophylline or theophylline dose?

If the IV aminophylline dose is 35mg/hr and the dosing interval for oral aminophylline and oral theophylline is every 12 hours, calculate the appropriate BD oral doses

A

The conversion from IV aminophylline to oral aminophylline is just a straight conversion so

1) work out the total daily IV dose: 840mg
2) divide by 2 to get BD dosing= 420mg BD
3) work out what the nearest dose according to tablet strength is (225mg tabs) = Phyllocontin Continus® 450mg PO BD

The salt factor for aminophylline to oral theophylline is approximately 0.8
Therefore in this case you need to times the totally IV dose by 0.8= 672mg
Could therefore give Uniphyllin Continus® 300mg in the morning and 400mg in the evening

57
Q

Describe the different types of Enteral Nutrition Tubes:

NG
NJ
PEG
RIG
PEJ
A

See notes

58
Q

Explain what Type C, D and E ADR’s are

A

Type C Reactions= ‘continuing’ reactions, persist for a relatively long time. An example is osteonecrosis of the jaw with bisphosphonates.

Type D Reactions+‘delayed’ reactions, become apparent some time after the use of a medicine. The timing of these may make them more difficult to detect. An example is leucopoenia, which can occur up to six weeks after a dose of lomustine.

Type E Reaction= ‘end-of-use’ reactions, are associated with the withdrawal of a medicine. An example is insomnia, anxiety and perceptual disturbances following the withdrawal of benzodiazepines.

59
Q

What are the three different types of incompatibility of drugs administered down tubes?

A

Therapeutic incompatibility- i.e. drug interactions, pH changes, altered renal excretion by one drug effecting another, enzyme induction resulting in altered metabolisms

Physical incompatibility: Interaction between 2 substances leading to change in colour, odor, taste, viscosity. Examples: insolubility, immiscibility (two liquid drugs wont mix)

Chemical incompatibility:
chemical reaction occurs between two substances changing its chemical properties e.g. oxidation, hydrolysis

60
Q

Describe the differences in IV access:

Peripheral line

Central line/ Hickmann line

PICC line

A

See notes

61
Q

What two vaccines are required for patients with COPD?

A

pneumococcal and influenza

62
Q

What criteria must be met to move up a step from 1 to 2 in the NICE/BNF asthma guidelines?

A

Using salbutamol inhaler three times a week or more

Having symptoms three times a week or more

Experiencing night time symptoms once a week or more

Had an asthma attack in the last two years

63
Q

What happens to Theophylline in smokers and alcohol users?

What is the target concentration for theophylline?

A

The plasma-theophylline concentration is decreased in smokers, and by alcohol consumption

10–20 mg/litre

Plasma-theophylline concentration is measured 5 days after starting oral treatment and at least 3 days after any dose adjustment. A blood sample should usually be taken 4–6 hours after an oral dose of a modified-release preparation

64
Q

Theophylline has a narrow therapeutic window, target plasma conc is 10-20 mg/L

What are signs of theophylline toxicity?

A

vomiting, agitation, restlessness, dilated pupils, tachycardia, and hyperglycaemia, also hyperkaleamia

65
Q

What conditions is theophylline levels increased by?

What conditions are levels decreased by?

A

The plasma-theophylline concentration is increased in heart failure, hepatic impairment, and in viral infections.

It is decreased in smokers, and by alcohol consumption.

66
Q

Plasma _____ levels should be monitored in patients with severe asthma, because beta 2 agonists, theophylline, corticosteroids can all cause ________

A

Potassium levels

Hypokaleamia

remember that these asthma medications all cause LOW potassium

67
Q

Preparations containing Phenytoin sodium are not equivalent to those containing Phenytoin Base. 100mg of Phenytoin Sodium is equivalent to ___mg of phenytoin base

A

Equivalent to 92mg

68
Q

Do aspirin / Nsaids increase the risk of Upper or lower GI bleeds?

A

Lower GI bleeds

69
Q

The Blatchford score and the Rockall score are measures for what?

A

For patients with acute upper GI bleeding

Blatchford score for first assessment

Full Rockall score after the endoscopy

70
Q

What clotting factors does warfarin inhibit?

A

Factor 2, 7, 9 and 10

Remember 2 + 7 = 9 then 10

71
Q

Clopidogrel interacts with PPI’s.. therefore what do we advised if these are to be given together?

A

Separate their administration by 2 hours

72
Q

Why do we assess the levels of the TPMT enzyme before starting therapy with azathioprine/ mercaptopurine in patient with Chrons ?

A

These drugs work by interfering with DNA synthesis and inhibiting proliferation of quickly growing cells.

TPMT is an enzyme that increases the metabolism of these drugs, so low levels of TPMT= more exposure to azathioprine/ mercaptopurine = risk of myelosuppression

73
Q

Mesalasine and sulfasalasine are used in which GI disorder?

A

Ulcerative colitis

74
Q

Why is chlordiazepoxide the benzodiazepine of choice in alcohol withdrawal?

A

It has a low dependent forming potential compared to other benzodiazepines

Alternative- diazepam

If severe/acute liver impairment= use lorazepam- so ask about LFTS, as impairment of liver will impair the metabolism of Chlordiazepoxide

75
Q

What is Terlipressin used for?

A

Variceal bleeding

76
Q

Where do Glycopeptides exert their action on bacterial cells? What are some examples?

A

GlycoPEPTIDes inhibit PEPTIDoglycan cross-links in the cell wall

E.g: Vancomycin, Teicoplanin

77
Q

What is the mechanism of Penicillins?

A

Inhibit enzymes that are responsible for cross linking peptidoglycans in bacterial cell walls

78
Q

How do Macrolides exert their bacteriostatic effects?

A

Macrolides:
Clarithromycin
Azithromycin
Erythromycin

Bind to 50S subunit of ribosomes inhibiting protein synthesis (similar to Aminoglycosides: bind to 30S subunit)

79
Q

Which conditions are Beta blockers used as secondary prevention;

NSTEMI
STEMI
Unstable Angina (all 3= ACS)
Stroke

A

All ACS conditions (STEMI, NSTEMI, unstable angina) involve a Beta blocker as secondary prevention

Beta blockers are contra-indicated in Stroke, however they can be continued if they are for another condition

80
Q

Co-careldopa contains Levodopa and Carbidopa

Co-beneldopa contains Levodopa and Benserazide

What are the roles of these different drugs in Parkinsons?

A

Levodopa= replenishes depleted striatal dopamine

Benserazide + Carbidopa= dopa-decarboxylase enzyme inhibitors, reduce the peripheral conversion of levodopa to dopamine BEFORE they cross the Blood Brain Barrier, hence limit side effects such as Nausea + Vomitting

Dopamine in the periphery= nausea/ vomitting. Metoclopramide= antisickeness= a dopamine anatagonist, but it crosses the BBB so shouldn’t be given in Parkinsons as it will increase PD symptoms! Use Domperidone to control N&V in Parkinsons patients

81
Q

Antimuscarinic drugs such as Procyclidine can be used in ________ Parkinsons disease

A

Drug-induced

remember procyclidine was always used to control EPSE’s in mental health patients as a result of their anti-psychotics

82
Q

Stalevo contains Levodopa Carbidopa and Entacapone. What is Entacapone for?

A

Its a COMT enzyme inhibitor which stops the peripheral breakdown of levodopa, similar to carbidopa which inhibitor dopa-decarboxylase enzyme

83
Q

What is the mechanism of Parkinsons drug Pramipexole and what can it cause if titrated too quickly?

A

Its a dopamine receptor agonist

Can cause dopamine excess- symptoms= nausea, vomiting, irregular heartbeat, anxiety

DIPLOMA (11 decks)

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