official mocks Flashcards
hx HTN, asthma, OA, haemorrhagic stroke 3 weeks ago
Bloods - Urea + Cr INCR, Na+ high, K+ high
what drugs need to be changed out of:
aspirin, lisinopril, paracetamol 1g 6hourly, ibuprofen 200mg
STOP aspirin - recent H stroke
STOP lisinopril - K+ high
CHANGE para dose - OD
STOP ibuprofen - Creatinine high
PE tx dose of what drugs
Enoxaparin sodium 120mg SC
Dalteparin sodium 1500U SC
when prescribing ACEi for hypertension in those under 55 when to give it
AT NIGHT (ON) as they can cause POSTURAL HYPOTENSION -remember that ACEi can cause hyperkalaemia
pt with stable angina - medication for relief of their CP
glyceryl trinitrate (GTN) spray - dose = 2 sprays - route = sublingual
what to give for rate control of AF if they have asthma
asthma –> can’t have beta blocker
-instead use CCBs = Diltiazem, Verapamil (RATE LIMITING)
mx of focal seizures in pregnancy
either lamotrigine or carbamazepine
- in pregnancy lamotrigine SAFEST
- carbamazepine can cause SIADH which causes drop in sodium
what patients can’t hv metformin
creatinine >150 or eGFR < 30
with regards to overweight diabetics and underweight diabetics what drugs are best
OW - Metformin
UW - SU
what is the risk of hypertension + being on COCP
increased arterial risk
with antipsychotics in which pts should you do an ECG
those with CV RF
for pt with impaired renal ftn + on digoxin tx what is IMP to monitor
Renally excreted so high risk toxicity if renal dysftn
propanolol common SE to tell pt about
FATIGUE
what are 3 big drugs to STOP before surgery
Antiplatelets - ASPIRIN
Anticoagulants - Heparin
COCP
+ omit lithium day before surgery
what drugs need altering before surgery - diabetic drugs
METFORMIN may be stopped day before surgery due to risk of lactic acidosis
Convert SC Insulin to SLIDING SCALE INSULIN INFUSION
if there is a paracetamol OD due to paras + co-codamol then what to do
stop PARACETAMOL
remember max 4g / day
daily dose of alendronic acid is what
and what is weekly dose in postmenopausal women
daily dose 10mg
weekly dose 70mg
does aspirin contribute to acute renal failure
NO even though it is an NSAID
so it can be continued !
what are examples of drugs that incr risk of ulcers
NSAIDs eg naproxen - inhibits PG synthesis needed for gastric mucosal protection from acid
Prednisolone - inhibits gastric epithelial renewal
link between thiazide diuretic and gout and what to do with thiazide diuretic
thiazide can cause gout so should STOP it
what to do if pt is on LT steroids and then going for surgery
LT steroids can dampen adrenal response so can’t respond adequately in times of stress –> profound hypotension
-so may need INCR in STEROID DOSE or IV steroids
must remember to check doses of common drugs
statins 40-80mg
paracetamol 1g
aspirin 75mg or 300mg
lithium toxicity caused by what common drugs and by what mechanism
so it can be either enzyme inhibitors OR reduced renal excretion eg by 1. ACEi 2.Diuretics esp THIAZIDES (if diuretic must be given then loop D are safest) 3. NSAIDs
if lithium toxicity shows evidence of arrythmias eg with palps what is definitive mx
DIALYSIS
What are dose changes of levothyroxine in increments of
25-50 microgram increments
roughly how many L of maintenance fluids / day for adults
3L = each bag over 8h (2 salty + 1 sweet)
for elderly - 2L - each bag over 12h
typically K+ 40 is only used for ppl with low K+ and 20mmol/L is better in the bags
what is imp to assess in pts with high k+
The clinical status - as it could be an artefact!
remember big increases of like 2.9 are unlikely
2 drugs to avoid when on methotrexate
trimethoprim + co-trimoxazole
-folate antagonists incr methotrexates effect as a folate antagonist and put pt at risk of severe SEs like BM supression and thus neutropenic sepsis
with olanzapine when should lipids be checked and in who do we do an ECG
lipids checked at baseline + every 3months for first year
-ECG in ppl with CV RF eg smoking as risk of prolongtion of QTc interval
what must ABx have on prescriptions
Start / review dates and indications for use
HAP mx mild and severe and how to write the one for severe
mild - PO Co-amoxicalv
severe - IV Piperacillin with Tazobactam
write it as Piperacillin/Tazobactam
CAP mx NICE
CAP:
- Mild Amoxicillin
- Severe = Co-amoxiclav + clarithromycin
Where to find mx of pneumonia in BNF
Search respiratory systems infections, antibacterial therapy
Heart burn Mx for immediate relief
- Short-term relief = Magnesium carbonate, 10mL, PO, TDS
- Long-term relief = Omeprazole, 10mg, PO
ACEi Side Effects
“ACEi” SEs = Angioedema (~4w) Cough Elevated K+ I (1st dose low BP)
some key monitoring for therapeutic effect
- for resolving DKA
- for ACEi
- for Vancomycin
- for cyclizine
Monitoring therapeutic effect:
GENERAL RULE - Clinical effect > biochemical effect
o DKA resolving = check ketones are going down (not glucose)
o ACEi = check serum creatinine first
o NORMAL PRE-dose ‘trough’ vancomycin = 10-15mg/L
o Anti-muscarinic side effects (Urinary retention, constipation, dry mouth, blurred vision) = cyclizine
painful eye and neck spasms - what is the dx and what is the mx
- and why is it not given PO
acute DYSTONIA = EPSE
- involuntary contractions of muscles of the extremities, face, neck, abdomen, pelvis, or larynx in either sustained or intermittent patterns that lead to abnormal movements or postures
- mx with PROCYCLIDINE
- this is given IM or IV as there may be an unsafe swallow
NB. Tardive dyskinesia is mx with tetrabenzine
-involuntary and abnormal movements of the jaw, lips and tongue
how to prescribe evorel conti in menopausal women who no longer wants a withdrawl bleed but HAS a UTERUS
Evorel conti is what you want but write it in full
= estradiol 50 micrograms / norethisterone acetate 170 micrograms / 24 hours
- 1 patch - transdermal - twice weekly
what drug is CI in probable PVD
B - blockers cause peripheral vasoconstriction + worsen ischaemia in PVD
in context of HF what is the problem with steroids and rate limiting CCBs eg diltiazem
they can worsen HF
what drugs can predispose pt to thrush
ABx - like amoxicillin + clarithromycin
also steroids - but only oral doses (low dose inhaled are inconsequential)
what dose of omeprazole for GORD
- 10mg oral daily incr to 20mg oral daily if sx return
- when looking for dosing errors remember to think about the condiitons they are used to treat as although dose might be safe in general the dose can still be wrong for that condition
sore throat, fever, runny nose, red throat, strawberry tongue, enlarged tonsils, blanching macular red rash what is dx
SCARLET FEVER
- strep infection
- needs PHENOXYMETHYLPENICLLIN
pt on warfarin gets a CAP and is treated with amoxicillin and Clarithromycin - her warfarin INR target is 3.5 but currently it is 3.3, what to do?
although her iNR is slightly below target, it is quite likely to rise due to co-prescribing clarithromycin so maintain the current dose + re-check it in 2 days
COCP missed 1 pill and her other pill is due today, what to do
take both, continue as normal
methotrexate highly teratogenic so what should you do if wanting to get pregnant
BOHT MEN + WOMEN –> use effective contraception whilst on it and for at least 6m after stopping tx
what kind of drug is indapamide and what is its effect on K+
it is a THIAZIDE LIKE DIURETIC
causes K+ to go DOWN
if a statin causes myopathy what tx should you do§
STOP statin if CK is markedly elevated (5x ULN) or if muscular sx are severe
-then if sx resolve + CK back to normal , you can restart at lower dose PO nightly
where can you find missed pill rules
it is a sectiion on the COCP page itself
so type in microgynon for example and then scroll down
what can be used for excess secretions at end of life
hyoscine hydrobromide
glycopyrronium bromide
-find this under prescribing in PC section
when deprescribing in geris what is a good drug to stop
bisphosphonates !
- you can find more info under osteoporosis tx summary in BNF
- Bisphosphonate treatment should be reviewed after 5 Y of tx with alendronic acid, risedronate sodium or ibandronic acid, + after 3 years of treatment with zoledronic acid
- Based on fracture-risk assessment, continuation beyond this period can generally be recommended for patients who are over 75 years of age, have a history of previous hip or vertebral fracture, have had one or more fragility fractures during treatment, or who are taking long-term glucocorticoid treatment
- There is no evidence for treatment beyond 10 years; management of these patients should be on a case-by-case basis with specialist input as appropriate
how to mx whooping cough if presentation is <21 days of onset of cough
Prescribe clarithromycin for infants less than 1 month of age.
Prescribe azithromycin (just says RTI) or clarithromycin for children aged 1 month or older, and non-pregnant adults.
Prescribe erythromycin for pregnant women.
if tx pt for hyperthyroidism and TSH still a little low what to do (and T3/4 a little high) ?
The patient is still showing hyperthyroidism on blood tests and needs to continue at her current dose of carbimazole
-NICE BNF states that patients should continue on 15-40 mg of carbimazole until the patient becomes euthyroid
-Once euthyroid, it should be gradually
reduced to 5-15 mg PO daily (titrated to TFTs) and is usually required for 12-18 months.
for pt on COCP whose BP rises to 166/93 what do you do
STOP COCP - absolute CI UKMEC 4 is BP rising to >160/100 and then you need to provide some cover so a POP is suitable to give
bells palsy mx other than eye lubricants
need prednisolone
-would be best to give high dose pred (such as that indicated for suppression of inflammatory and allergic disorders) –> 60mg daily for 5 days
citalopram dosing in young vs elderly
higher doses eg 40mg for younger
smaller doses eg 20mg for those >65
for a sick pt signs are oliguria –> incr HR –> decr BP in that order, if they are oliguric due to pre-renal AKI eg dehydration what fluid is appropriate if pt is mildly hyperkalaemic
cyrstalloids are ideal here - eg dextrose or saline
-then you should give the one without k+ due to mildly raised potassium
maintenance fluids in 80Y diabetic man
remember adults need 3L ie 8 hourly bags, of maintenance fluids except ELDERLY who need 2L per 24h ie 12hourly bags
- do not be afraid to give 5% dextrose to diabetic pts, by the time fliuid has circulated most of the glucose will have been metabolised so it will have little effect on plasma glucose
- REMEMBER NO GLUCOSE IF STROKE PT
phenytoin within normal range but gum hyperplasia + dysarthria (signs of toxicity), what should you do
if seizures are well controlled, even though phenytoin levels are in the normal range, it is safest to reduce dose phenytoin
when thinking about timings of maintenance vs replacement fluids
maintenance fluids - 12h
replacement fluids - 4h is sufficient
remember to check that you are not giving potassium faster than the recommended safe rate of 20 mmol / hour
for pts with hypotensive shock, due to bleeding, what to give
it is better to replace with fluids 0.9% saline STAT whilst you wait for cross matched blood
-IV blood transfusion can come after
post op nausea first line antiemetic and why not if long QT
ondansetron 5HT2 rec antagonist is first line
- avoid it pt already has long QT
- safer to give CYCLIZINE 40mg IV TDS (when a cannula is in place it is most appropriate to give drugs IV so any other route loses marks)
what electrolyte abnormality can ciclosporin cause
HIGH POTASSIUM hence it is monitored (esp in renal dysftn)
what to know about dosing of citalopram in elderly
MAX dose in elderly is 20mg daily!
what can all PPIs do to your bowels
cause loose stools + Diarrhoea (under common side effects of all PPIs) vs under freq not known for Pred
what 2 common drugs cause ankle swelling
amlodipine
NSAIDs eg naproxen!
thrush in pregnancy
AVOID systemic/oral tx
also requires a prolonged course (Not a one off pessary)
-CLOTRIMAZOLE PESSARY 100mg PV DAILY 7DAYS
acute shingles what to give for pain
paracetamol best
NB. for post herpetic neuralgia - amitryptilline is good for neuropathic pain but not in acute setting due to adverse anticholinergic effects
what drug to treat drug induced parkinsonism
procyclidine
is fentanyl an ok subsitute for morphine in acute pain
NO as it is a patch so the onset of action is toooo slow and it is less titratable
-although it does have less problems than morphine in kidney disease
what is a good substitute to morphine in kidney disease
OXYCODONE
-metabolised by the liver to inactive metabolites
amiodarone if tSH super low and T4 very high what to do with it
suggests thyrotoxicosis
-hold the amiodarone
elderly 74Y stroke pt NBM not e+d, bl glucose 7.2, what fluids
2L for elderly
NaCl is most imp
NOT glucose as it may worsen cerebral injury + his glucose is a little high here
needs potassium 70-80mmol / day roughly (be careful with rate)
Ideal: 1L 0.9% NaCl with 0.3% Potassium Chloride / 8-12h
statin for primary prevention if high QRISK score what dose + when to give
20mg
give at night
how does aspirin cause anaemia
due to inhibitory effects on prod of ATII and release of aldosterone
drugs that cause confusion
morhpine metoclopramide anticholinergics antipsychotics antidepressants anticonvulsants less commonly - H2 rec antagonists, digoxin, beta blockers, CS, NDAIDs, ABx
dehydrated pt and response to fluid therapy what to monitor
BP - responds quickest
what to do if peak dose gentamicin is HIGH
and what about if pre dose trough is HIGH
if peak dose high then REDUCE DOSE
if pre dose trough high then INCR INTERVAL
if both peak and trough concs are high
REDUCE DOSE + INCR INTERVAL
how to monitor adverse effects of HRT
cause soidum and water retention so you can monitor BP
