General Medicine & Medication Flashcards
Five types of medications used in Palliative care (be specific)
- Morphine
2.5mg-5mg Q1hourly (max 15mg/24hr) - Haloperidol
1mg Q4H - Midazolam
2.5mg Q2hourly - Glycopyrolate
0.2mg Q4H
Or Hyoscine butylbromide 20mg Q4H - Metoclopramide
10mg Q8H
Morphine dose for End of life
SUB CUT 2.5mg-5mg Q1hourly (max dose 15mg in 24hours)
Midazolam dose for end of life care
2.5mg Q2hourly (max 15mg)
Haloperidol dosing end of life care & use
1mg Q4H
Used for agitation and nausea
Secretion management in end of life care:
Option 1
Hyoscine butylbromide 20mg Q4H
Glycopyrolate 0.2mg Q4hH
Pain relief in Palliative care
Morphine:
Oral “ordine” Immediate release 2-5mg Q1H Max 6 doses in 24hrs
Morphine Slow release “MS contin: 5mg BD
Otitis externa treatment
- Dry Aural toiletting eveyr 6 hours until dry
- Dexamethasone + framycetin + gramicidin 0.05%+0.5%+0.005% ear drops, 3 drops , TDS for 7 days
Otitis externa treatment
2 short term
2 long term
- Dry aural toiletting 6 hours until dry
- Dexamethasone + framycetin + gramicidin 0.05%+0.5%+0.005% ear drops, 3 drops , TDS for 7 days
- If cant see TM or perforation
Ciprofloxacin + hydrocortisone 0.2% + 1% ear drops 3 drops instilled into the affected ear, twice daily for 7 days. - Isopropyl alcohol drops following water exposure
- Ear plugs
Fungal otitis externa
flumetasone+clioquinol 0.02%+1%, 3 drops, BD for 7 days
Otitis Media (when to use abx)
- Aboriginal
- Bilateral in <2
- <6months
- Ottorhoea
- Immunocompromised
Otitis media antibiotics
Amoxicillin 15mg/kg 8hourly 5 days
Causes of hypercholesterolaemia (8)
- Familial hypercholesterolaemia
- Hypothyroidism
- Cholestasis
- Chronic Kidney disease /nephrotic syndrome
- T2DM
- Excessive etOH
- Obesity
- Drugs (Oral oestrogens, thiazides, beta blockers, atypical antipsychotics)
Diagnostic criteria for familial hypercholesterolaemia (name of it and diagnostic score)
Dutch Lipid Clinic Network Diagnostic Criteria
>8 (more than 8)
>6 likely
Dutch Lipid Clinic Network Diagnostic Criteria
1) family history
- 1st deg with arcus cornealis or tendon - xanthomata (2)
- child <18 with LDL >95th centile (2)
- 1st deg with LDL >95th centile (1)
-1st deg with premature CVD (1)
2) Exam findings
- Arcus cornealis <45 (4)
- Tendon xanthomata (6)
3) Cholesterol levels LDL - C level
- 8.5 (8)
- 6.5- 8.4 (5)
- high
5) Clinical history
- premature CVD, pVD, cerebral vascular disease
Management of FH
1) Commencement of high dose statin (atorvastatin 40mg -80mg)
2) cascade testing (relatives)
3) Referral to Lipid specialist
4) Exercise Physiology
5) Dietician
6) consider ACEi given likely high risk CVD
Chronic diarrhoea DDx
- IBD
- IBS
- Chronic gastroinfection: giardiasis, cryptospiridium infection
- Coeliac disease
- Lactose intolerance
- SIBO
- Laxative abuse
- Endocrine causes: hyperthyroidism, addisons
Infanrix hexa - what is in it?
- Hep B
- Polio
- HIB
- Diptheria
- Tetanus
- pertussis
Paediatric dose of adrenalin
10mcg/kg IM
Anaphylaxis
- SUPINE
- IV access
- Bolus
- Adrenalin 10mcg/kg IM
- High flow 02
- 000
Central causes of vertigo
- Cerebellar CVA or haemorrhage
- Vertobasillar insufficiency (TIA)
- Migraine (vestibular)
- MS
Peripheral causes of vertigo
- BPPV
- Labyrinthitis
- Accoustic neuroma
- Vestibular neuritis
- Menniers
- Cholesteatoma
- Ramsay- hunt syndrome
- Superior semicircular canal dehissence
Features of peripheral vertigo
- Horizontal or torsional (torsional component) nystagmus that is suppressed with eye fixation.
- Unidirectional nystagmus
- Hearing loss may be present
- Walking preserved
Features of central vertigo
- Nystagmus: purely vertical or torsional
- Nystagmus can be reversible
- Severely unstable
- No hearing issues or tinnitus
- Other neurology (ataxia, diplopia, dysphagia)
Imaging for accoustic neuroma / central cause for vertigo
MRI with gadolinium contrast
Red eye questions
- Photophobia
- FB sensation
- Pain
- Vision affected
- contact lenses
- irritants
- truma
- discharge
RED EYE differentials
- Conjunctivitis
- Uveitis/iritis
- Keratitis ( HSV)
- Acute angle glaucoma
- FB
- Corneal abrasion
- Chemical keratitis
- Scleritis/episcleritis
Acute glaucoma emergency management
-SUPINE
-NBM
-Analgesia- morphine
-Dont patch
-transfer to ophthal
Oral iron supplement dose
100-200mg elemental iron daily
How to detect proteinuria (albuminuria)
- Urine ACR (First void ACR !!! is best)
- Repeat ACR (always do one) first void to confirm
(dipstick not sensitive enough)
Confirmed if 2/3 positive
CKD if present for 3 months
Anti-hyperglycaemic choice (after metformin) in HEART FAILURE
SGLT2 (dapaglifozin, empaglifozin)
Anti-hyperglycaemic choice (after metformin) in CARDIOVASCULAR DISEASE
**GLP1 **
(Liraglutide, dulaglutide, semaglutide)
OR
**SGLT2 **
(dapaglifozin, empaglifozin)
Celecoxib dose
100-200mg BD
Ibuprofen dose
200-400mg 8hourly
Naproxen dose
250-500mg BD
Sleep history
- Shift worker
- Jet lag
- Restless legs
- Snore
- Stimulants
- Mood
- Thyroid symptoms
- Quantify sleep
- Daytime function & symptoms
- Initiation (delayed sleep- wake phase disorder)
- waking overnight (Sleep maintenance insomnia)
- Early waking
THC (CBD oil with THC) Contraindicated in:
- Schizophrenia
- Past AMI
- Angina
Risk factors for Acute Rheumatic Fever
- ARF- endemic area
- ATSI rural/remote
- ATSI/Maori/islander metropolitan but low SES/overcrowding
- personal history of ARF or RHD
Management of sore throat:
Note: risk factors present for ARF
Benzylpenicillin G (IM)
OR
10 days BD phenoxymethylpenicillin
Major criteria for Acute Rheumatic Fever (ARF)
NOTE: Different for high risk vs normal risk
- Carditis
- Polyarthralgia, Polyarthritis, aseptic monoarthritis (polyarthritis in low risk )
- Sydenham chorea
- Erythema marginatum
- Subcutaneous nodules
Diagnostic criteria for acute rheumatic fever - initial episode
STREP evidence
PLUS
2 Major
OR
1 Major 2 minor
Minor criteria for Acute Rheumatic Fever (ARF)
HIGH RISK
- Fever 38
- Monoarthralgia
- ESR>30 or CRP >30
- Prolonged PR
Normal risk
- 38.5
- Polyarthralgia
- ESR 60
- CRP 30
- Prolonged PR
Treatment of Acute Rheumatic Fever
Benzathine benzylpenicillin IM
10kg-20kg: 0.6 million units (1.2ml)
>20kg: 1.2million units (2.3mL)
or oral
PMP 500mg BD 10 days
PLUS
ongoing dose every 21-28 days
Smoking cessation medication options
Nicotine Replacement
Varenicline (Champix)
Bupropion (Zyban)
Nortriptyline
Dose of Varenicline (Champix)
0.5 mg daily for 3 days,
then 0.5mg BD for 4 days,
then 1 mg BD for remainder of 12-week course.
Dose of Bupropion (Zyban)
150 mg daily for 3 days,
Then 150 mg BD for remainder of 9-week course.
Three
Contraindications for Bupropion
- Seizures
- Eating disorders
- MAOs
Counselling for Varenicline (Champix)
- Doubles the chance of quitting
- Nausea 30%
- Stop smoking in 2nd week of use
Nortriptyline counselling
Side effects
Side effects:
- Dry mouth,
- constipation,
- nausea,
- sedation
- headache,
- risk of arrhythmia in CVD
Start 10 to 28 days before quit date & continue for 12 weeks after
Pneumococcal vaccination >70 (non indigenous)
Prevenar 13
(13vPCV)
Pneumococcal vaccination ATSI
> 50
Prevenar (13vPCV)
23vPPV
12months later
then
23vPPV in 5 yrs
Shingrix vaccine counselling
- Non live
- Two doses (2-6 months between)
- > 50yrs immunocompetent
- > 18 Immunocompromised
- Higher efficacy
- Costly
- Only one available for immunocompromised
Zostavax counselling
> 12 months post shingles outbreak
> 50 allowed to use
60 recommended
70 on schedule
50 who are household contacts of immunocompromised
Contraindicated in Immunosuppressed:
- >20mg pred, chemo, radiation
- HIV
- Leukaemia/lymphoma
- DMARDS
Symptomatic treatment of acute vertigo
Prochlorperazine 5-10mg TDS 2 days
OR if vomiting/not tolerated then
Diazepam 5mg TDS for 2 days
OR Ondans 4-8mg TDS 2 days
OR Prochlorperazine 12.5mg IM then orally
SGLT2 example and dose
“GLIFOZINS”
Dapaglifozin: 10mg daily
(eGRF>25)
Empaglifozin: 10mg daily
Max dose 25mg
(eGFR>05)
DPP4 Inhibitor example and dose
“GLIPTINS”
Linagliptin 5 mg daily
GLP1 example and dose
“GLUTIDES”
Dulaglutide 1.5mg subcut WEEKLY
Liraglutide 0.6mg daily, increasing to max 1.8mg daily
Sulfonylurea example and dose
Gliclazide MR 30 mg daily
(max 120 mg)
Hypercalcaemia in metastatic disease (bone mets) management
- Hydration with IV normal saline
- Zalendronic acid IV
Time frame for ceasing COX2 inhibitors pre-operatively
3 days
Time frame for ceasing apixaban pre-operatively
24-48hrs
Preoperative testing for someone with ASA score 2 (eg diabetes well controlled)
FBC
EUC
ECG
(not routine for clotting)
Anticoagulation in severe renal impairment
Warfarin
with bridging enoxaparin 1mg/kg for 5 days until INR 2
Malaria prophylaxis (including dose and duration)
Doxycycline 100mg daily
1-2 days before leaving, 4 weeks after leaving endemic area
Other:
atovaquone / proguanil 250/100mg
1-2 days before leaving, 7 days after leaving endemic area
*** good for children
Paediatric formulation:
62.5/25mg tablet
** must have with fatty meal or full fat milk
Travel advice general
- Travel insurance
- Supply of prescription medications
- Bottled/filtered water
- Avoid street food/uncooked food
- First aid kit
- Mosquito advice: DEET containing repellent, long clothes, nets
- Avoid tattoos, sex, illicit drugs
- Avoid swimming in contaminated freshwater
Sexual assault management
- Referral to sexual assault referral centre
- Refer to community support group or counsellor
- Pregnancy risk
- STI testing 2,6,12 weeks
- Discuss reporting to police
- Assess for other injuries
- Assess for non-fatal strangulation
Q fever Treatment
Doxycycline 100mg BD 14 days
(even in children 2.2mg/kg)
Q fever clinical signs (when to suspect)
- Atypical pneumonia
- Any febrile disease
- Abattoir workers
- Exposure to animals
Leptospirosis clinical signs (when to suspect)
- Exposure to animals: rats, dogs, horses, cattle, pigs
- Freshwater swimming
- International travel, ecotourism in the tropics
- Abrupt fever, chills, myalgia, headache, rash, light sensitive conjunctivitis** (3 main signs)
Leptospirosis treatment
Doxycycline 100mg BD 7 days
Q fever causative agent
Coxiella burnetii
General malaise, fever, joint pain, headache story with travel to QLD, perhaps animal exposure…. DDX
- Brucellosis
- Leptospirosis
- Q fever
- RRV
- BFV
- EBV
- CMV
Tests for measels
- Nasopharyngeal PCR
- Urine measels PCR
- Measels IgG, IgM serology
Dengue symptoms
Fever
Headache
Retroorbital pain
Marked myalgia
Bone pain
When is tetanus immunoglobulin indicated
ONLY if
- Not complete course (3)(or unknown)
- AND Dirty or MAJOR wound
When is tetanus booster indicated
> 5 years
AND
Dirty/Major wound
Two tests for Latent TB
TST: tuberculin skin test
IGRA: interferon gamma release assay
*** BCG vaccine will cause positive skin test
Carcinoid symptoms
Skin flushing, diarrhoea, respiratory symptoms and valvular heart disease
Antiviral (tamiflu - oseltamivir) in pregnancy safe or not?
SAFE
Oseltamivir
Signs of lithium toxicity?
Vomiting, diarrhoea, ataxia, sluggishness, confusion, agitation, seizures, NM excitability (clonus, tremor)
DDx for lithium toxicity?
-Serotonin syndrome,
-neuroleptic malignant syndrome,
-etOH or benzo withdrawal
Risk factors for lithium toxicity ?
- Dehydration
- Acute illness
- Renal disease
- Drug interactions (ACEi, ARBs, NSAIDS)
Prophylaxis for bites/clenched fist injuries
Augmentin (22.5/3.2mg/kg to up 875/125mg) BD 3 days
Barriers to indigenous Australian’s having good health outcomes
Shortage of Aboriginal health workers
Poor health literacy
Mistrust in Western medicine
Lack of culturally safe health care services
Cultural or family duties
Distance to health care (remote/rural)
Witholding NOAC prior to surgery
1-3 days prior to procedure
HIGH risk bleeding: 3 days
Low risk 2 days
Witholding metformin before surgery?
Only in renal impairment stop before surgery or contrast
SGLT2s witholding prior to surgery advice? (hint time frame)
3 days prior to surgery
**unless day procedure (eg. scope- can be day of)
Nicotine patch dose
21mg/24hrs
Varenicline dose
0.5mg daily for 3 days the 0.5mg for 4 days then 1mg BD for remainder of 12 weeks course
Medications associated with Hyponatraemia
- Diuretics: indapamide, hydrochlorothizaide
- SSRis, SNRIs
- Carbamazepine
Hydrochlorothiazide cautions
- Not in <65yo
- Not in gout
Denosumab counselling
- Strict 6 months
- Osteonecrosis of the jaw risk- advise major dental work first
- Risk of atypical femur fracture
- Need to check Vit D prior to 1st dose
- 1300mg calcium per day
- Monitoring BMD 2 yrly
- Does not completely prevent fractures
Opioid poisoning dose of Naloxone
0.8mg IM stat
Best oxygen provision for opioid induced respiratory depression?
15L/min Bag valve mask at 10-20 BPM
(not nonrebreather)
Accepting gifts from patients: possible actions
- Discuss with medical indemnity insurer
- Discuss with colleague “peer test”
- Discuss with practice manager for advice on how to proceed
- Sensitively decline the gift
Malaria risk reduction non-pharmacological
Repellant with 15-30% DEET
Loose clothing
Mosquito nets
reapply repellant post swimming
avoid dusk and dawn
avoid perfume or aftershave
Suitability for home detox
- Supportive stable drug free environment
- No suicidal thoughts
- No previous withdrawal seizures
- No previous delirium tremenz
- no other drug use
DOACs preoperatively when to cease
2-3 days prior cease.
2 for low risk
3 days for high risk
Poor sleep (particularly being tired on waking & late bedtime) differentials
Depression/Anxiety
Stimulant use
Poor sleep hygiene
OSA
Narcolepsy
Delayed sleep phase disorder
Insufficient sleep
3 Zoononotic Infections to consider with fever chills, myalgias & fatigue
- Q Fever (coxiella burnetii)
- Brucellosis
- Leptospirosis
Treatment of Clostridium Difficile
Metronidazole 400mg 8 hourly for 10 days
Avoid PPis
Which two meds can you not use with Beta Blocker
Verapamil
Diltiazem
The three questions to screen for falls…
1) More than 2 falls in last 12 months?
2) Are you presenting following a fall?
3) Difficulty with walking or balance?
Signs of venous insufficiency
- Venous eczema
- Lipodermatosclerosis
- Varicose veins
- Haemosiderin deposits
- Venous flares
- Peripheral oedema
6 P’s of acute ischaemia’
Pallor
Pulselessness
Perishingly cold
Paralysis
Pain
Parasthesia
Emergency management of acute limb ischaemia
- Consult the vascular surgeon
- Protect the limbs with cage and heel pad
- Anticoagulation with heparin IV
- IV wide bore access
- IV fluids
- Analgesia
- Keep NBM
Drug dependent asking for opioid approach…
- Advise cannot be prescribed without a permit if history of opiate dependence
- Contact Medicare prescribing shopper helpline; Safescript;
- Contact Medicines Branch of Department of Health to ask whether has a known drug dependence
-Review past prescription history at practice; my health record
Contact usual pharmacy for past dispensing details
Referral to exercise physiologist; physiotherapist
Centrelink disability payment qualifiers:
- Must have a disability or medical condition that will last 2 years or more
- Needs to have a permanent impairment
- Must have a disability or medical condition that is fully diagnosed, treated and stabilised
- Must have a disability or medical condition that results in an impairment rating of 20 points or more (on Disability Support Pension Impairment Tables)
- Must have a disability or medical condition that will stop her working for at least 15 hours a week in the next 2 years
- Advise that Centrelink decides eligibility for a Centrelink disability support pension not the GP
ABI cut off for urgent referral
<0.4
ABI cut off for caution with
a) applying compression
b) no compression
<0.8
<0.7
Emergency management of Box Jellyfish sting
- Remove tentacles (use sea water)
- VINEGAR
- Then ice
Blue bottle management
- Salt water wash
- Hot water
Irukandji (Tiny box jellyfish) first aid
- Wash with sea water
- Remove tentacles
- HOT water
Young person syncope, some jerking movements, swift recovery differentials
- Seziure
- Vasovagal syncope
- Pseudoseizure
- Conversion disorder
- Cardiac arrhythmia eg long QT or WPW
- Basillar migraine
- Alcohol
Young person syncope, some jerking movements, swift recovery differentials
- Seizure
- Vasovagal syncope
- Pseudoseizure
- Conversion disorder
- Cardiac arrhythmia eg long QT or WPW
- Basillar migraine
- Alcohol
4 main features of management
- Strong pain relief eg Penthrox
- Tetanus booster
- Removal of foreign body under ring block
- Wound irrigation
- Cover with abx eg augmentin
All Animal bites what not to forget
TETANUS
Huntington’s percentage of inheritance
50% (Autosomal dominant)
Animal bite (eg deep cat bite) management
- Tetanus
- Irrigation
- Analgesia
- Antibiotics - augmentin
- Immobilise and elevate
Priapism management initial
- Cold shower
- Oral pseudoephedrine
- Gentle jog
Asymptomatic Carotid Artery Stenosis Management
- Aspirin
- Statin
- CVD risk factor modification
Antipsychotic for delirium for parkinsons or lewy body
QUETIAPINE 25mg PO
18 month vaccinations
Infanrix: DTP
MMRV
Act HIB
12 month vaccination
Meningococcal ACWY (nimenrix)
Pneumococcal (prevenar 13)
MMR
*bexsero for ATSI
6 month vaccinations
Infanrix hexa: DTP, Hepatits B, polio, HIB
6 week and 4 month vaccinations
Infanrix hexa
Pneumococcal (prevenar13)
Rotavirus
PLUS bexsero
Year 7 vaccinations
DTP
HPV
