imperial mock errors Flashcards
after starting lithium, after what time should you measure the dose
Lithium levels are normally measured one week after starting treatment, one week after
every dose change, and weekly until the levels are stable. Once levels are stable, levels are
usually measured every 3 months. Lithium levels should be checked 12 hours post dose.
TFTs and U&Es need to be measured every 6 months.
starting serotonin important safety net to provide
seek urgent med attention if you get high temp + tremor = SEROTONIN SYNDROME
- Autonomic hyperactivity (sweating, tachycardia)
- NM abnormality (tremor)
- Mental status changes (confusion, agitation)
medication for thrush
It can be
treated orally with fluconazole 150 mg once, or itraconazole 200 mg BD for one day
OR
10% clotrimazole cream, 5g, by vagina, ON
OR
Clotrimazole pessary 200 mg vaginal once at night
write this as you would prescribe it :
Clotrimazole
Vaginal candidiasis (dose for 10% intravaginal cream)
By vagina using vaginal cream
Adult
5 g for 1 dose, one applicatorful to be inserted into the vagina at night, dose can be repeated once if necessary.
10% clotrimazole cream, 5g, by vagina, ON
medication overuse headache what drugs put you most at risk
Opiods and triptans + association with psychiatric co-morbidities
52Y - ABPM BP 144/92 - classify this and then would you treat
This man has stage 1 hypertension (BP>135/85 - <150/95) on a bg of DM
+ asthma
-NICE guidelines state that, in patients <55 years old, stage 1 hypertension
should be treated if there is a history of diabetes, CVD, renal disease,
evid of end organ damage, or a 10-year CV risk (Q-Risk2) of >10%. ACEi are 1st line + the doses listed above are the approved starting doses.
ARBs such as losartan or candesartan can be used if ACE-i are not tolerated
-This man has no hx of drug allergies or intolerances, so a low-dose ACE-i would be the correct choice
-The bg of asthma would mean
prescribing beta-blockers is contraindicate
-Stage 2 hypertension (BP >150/95) should
always be treated regardless of co-morbidities.
swithcing antidepressants
initially a different SSRI or a better tolerated newer-generation antidepressant
subsequently an antidepressant of a different pharmacological class that may be less well tolerated, for example venlafaxine, a TCA or an MAOI.
Second-degree tear of the perineum. Booking weight 60 kg.
She requires lidocaine 1% solution to the perineum for the repair. Maximum dose of
lidocaine 1% is 4.5 mg/kg.
Calculation
What maximum volume (mL) of lidocaine this patient can be given?
4.5 x 60 = 270mg
lidocaine 1% = 10mg in 1 ml
so she requires 27ml
pt with hysterectomy wants to start HRT , she prefers transdermal
- what type is she suitable for
- prescribe it
No womb so can have CONTINOUS OESTROGEN ONLY HRT
Transdermal = Elleste Solo MX40, Estraderm MX25, Evorel 50
EG NAME: Elleste solo MX 40 transdermal patches 1 patch OD transdermal FREQUENCY = TWICE WEEKLY
otitis media with pen allergy in 1 year old girl who WEIGHTS 10KG importantly
usu amoxicillin but allergic SO
Clarithromycin 62.5 mg oral twice a day
- NEED TO CHECK BNFc for the correct dose / weight
10 year old child with acute severe asthma attack
- calculated PEFR as 45% as predicted for age/height
As per the BTS/SIGN guidelines for children aged 1+, this this patient would be classed as having
an ‘acute severe’ asthma attack (PEFR 33-50% predicted and RR >30 breaths per minute).
Management for an acute severe asthma attack is urgent transfer to hospital, B2 agonists
and early steroids. Inhalers with spacers are recommended in mild-moderate asthma
attacks, and oxygen is only advised if saturations are less than 94%, or the child has a ‘life
threatening’ attack.
A 66-year-old woman has a QFracture risk of 14.3%. PMH. Depression and COPD (requiring
steroids for exacerbations around three times a year). DH. Sertraline 100 mg PO once daily,
Anoro Ellipta (Umeclidinium bromide 65 microgram/Vilanterol trifenatate 22 microgram)
55 micrograms INH once daily. SH. Smokes 20 cigarettes/ day.
prescribe a drug
This patient has several factors, which make her high-risk for having osteoporosis, such as
her age, gender, smoking history, and steroid use. These factors mean this patient should be screened for fragility fracture risk using the FRAX or QFracture risk assessment tools, and a DXA scan organised as applicable. A T-score of -3 on a DXA scan demonstrates osteoporosis.
1st line management is a bisphosphonate – either alendronate or risedronate. Calcium and vitamin D supplementation may also be needed.
Alendronic acid 10 mg oral once a day
Alendronic acid 70 mg oral once a week
Select ONE prescription which should be stopped while he is taking clarithromycin.
A. Amlodipine 5mg PO daily
B. Atorvastatin 10mg PO daily CORRECT ANSWER
C. Omeprazole 20mg PO daily
D. Salbutamol 1 to 2 puffs INH as required
E. Symbicort 1 puff INH twice daily
The patient is allergic to penicillin, so clarithromycin is an appropriate alternative
treatment for acute otitis media. Clarithromycin is a macrolide antibiotic. Macrolides are
potent inhibitors of cytochrome P450 liver enzymes and can therefore interact with drugs
that are metabolised via this pathway. Atorvastatin (like other statins) is cleared from the
bloodstream by CYP3A4, which is inhibited by clarithromycin. Taking statins and
clarithromycin together could lead to increased levels of statin in the blood. This could
cause severe side effects or, more seriously, acute renal failure and rhabdomyolysis. Statins
should be withheld while on macrolide antibiotics and can be re-started as soon as the
course is complete.
PMR mx
PMR mx Prednisolone 15mg OD
-Patients should be reviewed after one week to assess the clinical response and, if
improving, the dose can be reduced slowly after 3 to 4 wee
risperidone which adverse effect is most likely - angioedema, diarrhoea, dry eyes, flushign, vaginal discharge
all possibile but DIARRHOEA is the most common and specific to risperidone
mx of PTSD
According to the latest NICE Guidelines, an SSRI or venlafaxine can be given for the
management of PTSD, alongside other non-pharmacological management strategies, such as
CBT and Eye Movement Desensitisation and Reprocessing (EMDR).
The guideline states: Consider venlafaxine or a selective serotonin reuptake inhibitor
(SSRI), such as sertraline, for adults with a diagnosis of PTSD if the person has a preference
for drug treatment. Review this treatment regularly.
Analgesia when breastfeeding
Codeine should be avoided in BrFeeding as it carries a risk of breathing diff in infant
-Codeine is not rec in breastfeeding due to a risk of SEs in the baby such as: breathing problems, lethargy , poor feeding, drowsiness and
bradycardia
-Both paracetamol and ibuprofen are safe for use in breastfeeding. They can be
used together to treat severe pain. If the baby needs to take paracetamol, transfer from the
mother’s medication is too small to be harmful in addition. Both can take their own full and normal doses
- Aspirin is not recommended in breastfeeding as it carries a risk of Reye’s
syndrome in the infant.
emergency contraception timings
3 x key types and times
Levonorgestrel is effective if taken within 72 hours of unprotected intercourse and may also be used between 72-96 hours [unlicensed use], however its efficacy decreases with time.
Ulipristal Acetate (EllaOne) should be considered as the first-line hormonal emergency contraception for a woman who has had unprotected intercourse in the last 120 hours. (avoid in servere asthma controlled with oral GC)
Insertion of a copper intra-uterine device is the most effective form of emergency
contraception and should be offered (if appropriate) to all women who have had
unprotected sexual intercourse and do not want to conceive. A copper intra-uterinecontraceptive device can be inserted up to 120 hours (5 days) after unprotected
intercourse. However, this patient does not want a coil inserted and also has a history ofmenorrhagia, which can be exacerbated by the copper coil.
for children <5Y with asthma how should you monitor asthma control at each review
NICE - Monitor asthma control at each review in anyone aged 5 years and over using either spirometry or peak flow variability testing. (twice daily)
menorrhagia mx
For women with no identified pathology, fibroids less than 3 cm in diameter, or suspected or diagnosed adenomyosis:
1st - hormonal LNG-IUS = mirena
-if declined or unsuitable
-TRANEXAMIC ACID 1g PO 3X/D when bleeding or NSAID
OR Hormonal - CHC or COCP
pt with fibromyalgia - pain not controlled with paracetamol wants to try an antidepressant - what is the best option
AMITRYPTILLINE & NORTRIPTYLINE (10mg starting dose)
both TCAs
NB. strong opiods NOT recommended
what can sumitriptan and lithium interact to cause
Serotonin Syndrome
A 44-year-old man recovering on the inpatient ward has difficulty sleeping for the past
three days. He is distressed at the lack of sleep he is getting which is worsening his anxiety.
PMH. Depression and anxiety. DH. Fluoxetine 20 mg PO daily. prescribe a medication to help him sleep
ZOPICLONE 7.5MG
importantly it is ON !!
If sleep hygiene measures fail, daytime impairment is severe causing significant distress, and insomnia is likely to resolve soon (for example due to a short term stressor):
Consider a short course (3-7 days) of a non-benzodiazepine hypnotic medication (z-drug).
-• Do not prescribe hypnotics routinely — use only for short courses if acutely distressed.
• Do not prescribe hypnotics to older people or women who are pregnant or breastfeeding.
reasons HRT should be STOPPED (9) and where to find this info - sex horomones - oestrogens and HRT - BNF scroll down
The patient is showing symptoms of a drug-induced hepatitis with a transaminitis and
jaundice after starting HRT
-As per NICE guidelines, HRT should
be stopped (pending investigation and treatment), if any of the following occur:
• sudden severe chest pain (even if not radiating to left arm);
• sudden breathlessness (or cough with blood-stained sputum);
• unexplained swelling or severe pain in calf of one leg;
• severe stomach pain;
• serious neurological effects
• hepatitis, JAUNDICE, liver enlargement;
• blood pressure above systolic 160 mmHg or diastolic 95 mmHg;
• prolonged immobility after surgery or leg injury;
• detection of a risk factor which contra-indicates treatment.
unvaccinated child with drooling, stridor
There is a high clinical suspicion of Epiglottitis in an unvaccinated child with stridor,
drooling and respiratory compromise.
NICE guidelines state that antibiotic therapy for Epiglottitis is Cefotaxime or Ceftriaxone as
first line.
- If there is a history of immediate hypersensitivity to penicillins or cephalosporins,
Chloramphenicol is a suitable second line option.
-Cefotaxime dose is 50mg/kg every 8-12 hours
-Ceftriaxone dosage is 50–80 mg/kg once daily, doses at the higher end of the recommended
range used in severe cases; maximum 4 g per day.
NB. Oral options would not be suitable in this child due to the acuity and airway obstruction.
lymecycline = oral ABx- what advice to pts
causes photosensitivity
- use in acne 2nd line after topical preparations for a MAX OF 3 MONTHS
- topical retinoid (if not CI) or benzoyl peroxide should be co-prescribed with oral ABx to reduce risk of ABx resistance
A 24-year-old woman has polycystic ovary syndrome. She has approximately two periods a
year. Her last period was 5 months ago. She has no plans to get pregnant.
On examination
BP 115/70 mmHg. BMI 25.4 kg/m2.
A transvaginal ultrasound scan has been arranged.
Prescribing request
Write a prescription for ONE drug that would be appropriate to induce a withdrawal bleed
in this patient.
NICE CKS -
if W has prolonged amenorrhoea (less than 1 period every 3 months) prescribe a CYCLICAL PROGESTOGEN eg MEDROXYPROGESTERONE 10mg DAILY FOR 14 days to induce a withdrawl bleed
-then refer for TVUSS to assess endometrial thickness
coeliac pt with low Hb and low ferritin and normal folate and b12 who is tired - what is dx + what tx
IDA
- duodenum likely affected as this is where iron is absorbed
- mx with ORAL FERROUS SULFATE
NICE CKS on Iron supplements:
• The aim of treatment is to restore Hb levels + red cell indices to normal, + replenish iron stores.
• A dose of 65 mg elemental iron (ferrous sulfate 200 mg) three times daily is needed to treat iIDA. but, dose-related adverse effects from taking an iron supplement are commonly experienced.
• Adverse effects can be reduced by taking iron with food.
• Alt, lower doses may be eff. and better tolerated — consider reducing the dose to ferrous sulfate 200 mg (65 mg elemental iron) twice a day until
the clinical response is assessed after 2–4 weeks.
• Alt, if ferrous sulfate is not tolerated then the person may prefer taking a diff iron preparation.
• Ferrous gluconate 300 mg tablets may be better tolerated than ferrous sulfate as there is less elemental iron content per tablet than ferrous sulfate.
• Ferrous fumarate tablets contain more elemental iron per tablet than ferrous sulfate so are likely to be no better tolerated
