Official mocks Flashcards
treatment for pulmonary oedema than requires immediate treatment
Loop diuretic:
- furosemide IV
DOSE = 20 -50 mg
(other optimal answer would be glyceryl trinitrate 50mL infusion
What is the first line IV treatment for hypoglycaemia?
Glucose 20%
- if not available, glucose 10% is a suitable alternative
Infusions of 10% (100-200mL) or 20% (50-100mL) deliver between 10-20g of glucose.
Infusion rates up to 20 minutes are optimal
Glucose 50% is hypertonic so risks extravasation
Glucose 5% is too weak & a large volume would be required
What are some suitable treatments for acne that has not responded to topical therapy?
Tetracycline 500 mg PO BD
Doxycycline 100mg PO OD (doesn’t have to be taken at certain times e.g. with food)
Which 3 of the following are most likely contributing to hyperkalaemia?
atorvostatin co-amox dalteparin sodium lactulose mycophenolate mofetil oxycodone PCM prochlorperazine ramipril tacrolimus
& which to be adjusted?
Dalteparin (and all heparins)
- via inhibition of aldosterone synthesis
Ramipril:
- via reducing aldosterone
Tacrolimus
- due to reduced potassium escretion
Adjust: ramipril first, then tacrolimus (with a serum conc) and finally dalteparin
Do you need to stop aspirin before surgery? if so how long before?
YES
one week prior to surgery
main exemption is if a pt has recieved recent vascular stenting, in which case surgery is usually held off until the crucial antiplatelet period has finished as they are high risk for stent thrombosis if antiplatelet agents are stopped too early
Which 2 should be withheld in an AKI until renal function recovers?
allopurinol 300mg
amitriplyline
bisoprolol
candesartan
ACE-i & ARBs (candesartan) are nephrotoxic so should be suspended
Allopurinol can accumulate in renal dysfunction & max dose should be 100 mg until renal function improves
Which 3 of these drugs are most likely to be causing confusion in an elderly man who has high urea and high Cr?
a. clopidogrel
b. atorvostatin
c. co-codamol
d. diazepam
e. doxycycline
f. prednisolone
Pt has developed AKI, can result in reduced clearance of medicines and an increase in adverse effects.
- so codeine and dizepam retention may be contributing
Glucocorticoids can also cause confusion particularly in the elderly
What 2 drugs are most likely to be causing hyponatraemia?
- aspirin
- bendroflumethiazide
- citalopram
- levothyroxin
bendroflumethiazide: well known cause of hypoN
SSRIs: recognised complication of SSRIs, via inappropriate ADH secretion
How often should levothyroxine sodium be taken?
daily
what is isaphula husk?
a bulk-forming laxative
what do laxatives do to potassium?
they cause hypOkalaemia
- cause loss of potassium in the stool
Pt with metastatic cancer, intermittent acute onset, severe pain in her back
DH: fentanyl 50 micrograms/h transdermal patch, one patch applied 72-hourly
PCM 1g PO 6-hrly
most appropriate management option at this stage?:
a. buprenorphine 10 microograms/h transdermal patch one patch applied 4-hourly PRN
b. fentanyl 50 micrograms/actuation nasal spray one spray to one nostril repeated once after 10 mins as required
c. morphine sulfate 10 mg PO 4-hrly as required
b. fentanyl 50 micrograms/actuation nasal spray one spray to one nostril repeated once after 10 minutes as required
- pts receiving at least 25 micrograms of transdermal fentanyl per hr can use nasal fentanyl for breakthrough pain
- max initial dose is 50 micrograms into one nostril, repeated once if necessary after 10 mins (with max of 2 sprays for each pain episode and a minimum of 4 hrs between each treatment of episode.
- F is absorbed rapidly from nasal mucosa so acts quickly
(morphine sulfate dose is too low in this scenario. additionally, its advised that the same drug be used for regular and breakthrough pain relief - nasal spray likely to provide faster relief)
79 yr old male with UTI
DH: folic acid 5mg PO daily, allergic to penicillin
which antibiotic
a. co-amox
b. nitrofurantoin m/r 100 mg PO 12-hourly for 3 days
c. nitrofurantoin m/r 100 mg PO 12-hourly or 7 days
d. trimethoprim 200 mg PO 12-hrly for 7 days
Trimethoprim 200mg PO 12-hourly for 7 days
( it blocks folate metabolism, and may therefore exacerbate pre-existing folate deficiency, but this doesn’t preclude its use for a short course of treatment. 7 day course is indicated in a male)
First line treatment in alcohol withdrawal?
Benzodiazepines
e.g. chlordizepoxide hydrochloride 20mg PO 6 hourly
Peri-operative anticoagulation for a patient who is on warfarin
Warfarin should be stopped 5 days before elective surgery
Phytomenadione (vitamin K1) by mouth (using the intravenous preparation orally [unlicensed use]) should be given the day before surgery if the INR is ≥1.5. If haemostasis is adequate, warfarin sodium can be resumed at the normal maintenance dose on the evening of surgery or the next day.
Patients stopping warfarin sodium prior to surgery who are considered to be at high risk of thromboembolism (e.g. those with a venous thromboembolic event within the last 3 months, atrial fibrillation with previous stroke or transient ischaemic attack, or mitral mechanical heart valve) may require interim therapy (‘bridging’) with a low molecular weight heparin (using treatment dose). The low molecular weight heparin should be stopped at least 24 hours before surgery; if the surgery carries a high risk of bleeding, the low molecular weight heparin should not be restarted until at least 48 hours after surgery.
What is the most important information you should tell a patient starting rivaroxaban?
- if he misses a dose he should take 2 tablets the next day
- rivaroxaban can cause dry mouth
- rivaroxaban should be taken with food
- st johns wort should be avoided when taking rivaroxaban
Should be taken with food to improve absorption
A 28yr old is started on topiramate 25mg PO daily for migraine, she is sexually active and taking desogestrel 75mcg PO daily
what advice to give her about contraception?
She should change to an alternative method of contraception until 4 weeks after she has ceased taking topiramate
- The efficacy of oral progestogen-only preparations is reduced by enzyme-inducing drugs such as topiramate, and an alternative C method, unaffected by the interacting drug, is recommended during teratment with an enzyme-inducing drug and for at least 4 weeks afterwards.
https: //bnf.nice.org.uk/treatment-summary/contraceptives-interactions.html
how many nanograms in a microgram?
1000
Which is the most likely adverse effect to be caused by beta-adrenoceptor blockers?
- ED
- hypoK
- rash
- sedation
- wt gain
= BB
Sexual dysfunction (including ED), is a recognised adverse effect of B-adrenoceptor blockers, frequency not known
Which of the following drugs is most likely to contribute to jaundice?
- aspirin
- bisoprolol
- co-amox
- metformin
- PCM
cholestatic J can commonly, or very commonly occur, either during or shortly after Rx with co-amoxiclav
risk of acute liver toxicity is 6 x greater with co-amoxiclav than with amoxicillin
cholestatic J is more common above the age of 65 and in men
Which prescription is most likely to interact with dabigatran etxilate to cause GI bleeding?
- amlodipine
- bisoprolol
- citalopram
- digoxin
- metformin
citalopram has been reported to increase the risk of bleeding events with dabigatran, esp GI haemorrhage, particularly in the over 65s
what do you do if someones creatinine rises by <20% when starting an ACE inhibitor?
continue it and repeat U&Es after 1 week
- small rise (<20%) is expected and dosen’t require Ix or change in prescription
whats the most appropriate option to monitor for beneficial effects of IV furosemide after 2 days of treatment?
Weight
RR isnt good as is confounded by too many other factors
What is best monitoring test for adverse effects of carbimazole within 2 weeks of starting treatment, (in a pt presenting with sore throat)
FBC
Neutropenia is a less common, but potentially serious, adverse effect of carbimazole
If peridopril erbumine is used for heart failure treatment, whats best way to monitor for beneficial effects of it over the first month?
- exercise tolerance
- HR
- pro brain natiuretic peptide
- serum creatinine
- troponin
exercise tolerance
Whats the most appropritae option to monitor for adverse effects of ciclosporin after 2 weeks of treatment?
- fasting lipid profile
- FBC
- HBA1c
- serum creatinine
- urinalysis
- serum creatinine
most serious adverse effects are nephrotoxicity and HTN (mediated by vasoconstrictive effects on renal arterioles)
- before initiation of Rx, baseline assessment of RF should be established and RF should be monitored every 2 weeks until results are stable.
- BP should also be monitored on a regular basis
[although leucopenia and thrombocytopenia may occur in pts treated with ciclosporin, RF is more important, esp in the first 2 weeks of Rx. FBC should be taken monthly until results are stable, then every 3 months]
Transient rise in blood glucose caused by corticosteroids in T1dM? what Mx?
an increase in the usual insulin dose of 10% would be an appropriate way to manage this
What is a normal fasting blood glucose? whats pre-diabetes? whats diabetes?
<5.6 mmol/L = normal
(5.6 to 6.9 mmol/L) is considered prediabetes.
If it’s 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.
A man gets started on atorvostatin 20mg PO OD for hypercholesterolaemia 3 months ago.
His serum HDL remains 1.5 (>1.55), but his serum LDL cholesterol has decreased to 2.1 from 4.1
what do you do regarding his statin?
keep it the same
As after 3 months of treatment a >40% reduction in non-HDL cholesterol has occured
Someone’s started on gentamicin, the chart cant be read until 6hrs after first dose given. the conc you have is from 4 hrs post dose. what to do?
repeat the blood test 2 hrs later
other options include working out the pts creatinine clearance or discussing with micro
Pt with exacerbation of COPD, over past 3 days. What to prescribe her?
High-dose nebulised B2 agonist is first line
- Give as early as possible
Salbutamol or Terbutaline
[add ipratropium bromide (500mcg NEB) to B2 agonist treatment for pts in those with a poor initial response to B2 agonist therapy. Salbutamol alone should be tried first]
Pt needs 10 500 units of tinzaparin, what do you prescribe?
A dose of 11 000 /(or 10 000) units is practical for administration
If patient has had a stroke 7 days ago, and been E&D less and unwell for 2 days. Now can’t swallow.
Na+ 144
Random plasma glucose 7.2
What IV fluid to give?
If the patient is symptomatic: for Dx of DM
- fasting glucose greater than or equal to 7.0 mmol/l
- random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
So.. I think we assume this random one was actually a fasting one? Even though fasting is supposed to be 8hrs after last meal, and we can’t be sure of that.
But right answer = sodium chloride 0.9% / potassium chloride 0.3% 1000mL over 8-12 hours
!!!! Glucose-containing fluids have the potential to exacerbate cerebral injury - so don’t use (current glucose is elevated)
What to give for hypercholesterol in a pt with a 10-year risk of cardiovascular disease of 10% or more?
/ most type 1 TDM or CKD with eGFR <60
Atorvastatin
20mg OD
(if non-HDL has not fallen by >/= 40% then consider titrating up to 80mg)
Which 2 most likely to cause haematemesis? & why?
- amlodipine
- aspirin
- digoxin
- ibuprofen
- metformin
- ramipril
- senna
& which 2 most likely to be contributing to renal impairment?
- aspirin
- ibuprofen
Both inhibit COX and the production of prostaglandins that protect the gastric mucosa against acid-related erosion & ulceration
(also can cause damage through some other mechanisms too)
- rampiril & ibprofen
(digoxin will accumulate in renal imapriment, but won’t cause decreased renal function)
which most likely to cause dehydration?
- amiodarone
- amitriplyline
- atenolol
- bendroflumethiazide
- prazosin
- spironolactone
bendro: thiazide-like diuretic, can cause excessive sodium and water loss
spiro
What 3 drugs should be stopped due to results : hyperkalaemia, renal impairment, and iron deficiency anaemia?
and which 1 might be causing hypoglycaemia?
- amlodipine
- aspirin
- doxazosin
- ezetimibe
- metformin
- pioglitazone
- ramipril
- simvastatin
Ramipril –> likely to cause hyperK and renal impairment
Metformin is CI in pts with significant renal impairment or who are acutely unwell and tissue hypoxia is likely
Aspirin is likely cause of iron deficiency anaemia
b. pioglitazone:
a. What drug most likely to cause urinary rentention in the postoperative period?
b. what 2 are contributing to confusion?
- candesartan
- co-amox
- dalteparin
- metoclop
- morphine sulphaste
- PCM
a. morphine and other opiod analgesics can cause urinary retention, esp in the early postoperative period
b. metoclopramide hydrochloride & morphine
What are some drugs that commonly cause urinary retention?
- anticholinergics (e.g. antipsychotic drugs, antidepressant agents, anticholinergic resp agents, detrusor relaxants)
- opioids
- general anaesthetics
- alpha-adrenoceptor agonists (e.g. doxazosin)
- benzos
- NSAIDs
- CCBs
- antihistamines
- alcohol
What is strongly indicated in a pt with long history of alcohol abuse and disorientation who may have/ or is at risk of WE?
IV vitamin B
- even if pt presents with tablets of thiamine, doesn’t mean he hasn’t got critical deficit of vitamin B that might threaten his neuro function
T1DM with ketones + 2, and finger prick glucose of 28, (also hyperkalaemia), how to treat?
soluble insulin 50 units in NaCL 0.9% 50 mL by IV infusion at a rate of 0.1 units/kg/hr
(this is first line over calcium resonium [calcium polystyrene sulfonate])
Whats the folic acid dose for pregnany lady?
Depends on risk of conceiving a child with a NTD
- if low: 400 mcg daily before conception and until week 12 of pregnancy
- if high (e.g. FH of spina bifida) : 5 mg daily until week 12
Does alendronic acid:
a. stimulate the cells that form new bone?
b. reduce the incidence of further vertebral and non-vertebral fractures in pts with osteoporosis
b.
when is oestrogen combined with a progestogen for HRT?
& why?
for women with an intact uterus
to reduce the risk of endometrial carcinoma associated with unopposed oestrogen
If a solution is 0.1%, how do you express this as a weight per volume?
0.1g per 100mL
100mg per 100mL
1mg/mL
what age group does ototoxicity (and nephrotoxicity) occur most commonly in those taking aminoglycosides?
elderly
what drug is most likely to be interacting with simvastatin to cause aching?
- amox
- aspirin
- clarithro
- lisinopril
- metformin
Clarithromycin
- it interacts with many drugs that are metabolised via the cytochrome P450 system (CYP 34A) including simvastatin
- which is morelikely to cause muscle aching when its metabolism is inhibited and its clearance slowed
Give some drugs that may cause anaphylaxis?
NSAIDs B-lactam abx (penicillin, cephalosporins) Aspirin Chemo Vaccines Parenteral iron injections Herbal preps
some cause reactions by directly triggering mast cell degranulation e.g. vanc, morphine, x-ray contrast
Best monitoring option to assess beneficial effects of allopurinol for gout?
serum urate
as A inhibits the activity of the enzyme xanthine oxidase
Best monitoring to assess the adverse effects of lithium carbonate?
renal function test
can impair renal function, and can cause nephrotic syndrome and nephrogenic DI
Best monitoring to assess the adverse effects of HRT?
BP
HRT can cause sodium and fluid retention, which can lead to a rise in BP
HRT should be stopped if BP rises above systolic 160 mmHg or diastolic 95
What do you do if pts started on simvastatin 40mg PO nightly for high cholesterol and ALT comes back 3 months later as 70 (5-35)?
- continue it at same dose
Guidance: liver enzymes should be measured before Rx, and within 3 months and 12 months of starting Rx (unless otherwise indicated).
- Pts with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, shouldn’t be routinely excluded from statin therapy
- those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin
what drug can exacerbate angina?
levothyroxine
- so cautious dose titration is needed to avoid exacerbating angina
Baby’s peak serum gentamicin is 12 (5-10) and trough serum is 3 (<2), what to do?
dose needs to be decreased (determines peak)
interval needs to be extended (determines the trough)
- trough conc indicates the conc to which potential targets of toxicity (e.g. ear and kidney) are constantly exposed
What HRT to give someone without a uterus?
Oestrogen-only HRT (if no uterus / mirena in place)
Pill, transdermal patch or gel
PILL: Estradiol 2mg
PATCH: Esetradiol
GEL : Estradiol
Who requires contraception alongside HRT?
and when is contraception NOT required?
<55y and sexually active and menstruating
NOT if:
= 50y and has been amenorrhoeic for >/= 2y
> 50 and has been amenorrhoeic for >/= 1y
What type of HRT/contraception to give pt who has a uterus and requires contraception? & examples
- Oestrogen-only pill, patch or gel + Mirena (other IUSs not licensed for endometrial protection) e.g. estradiol
- Combined hormonal contraception (if eligible) : e.g. Femoston Conti [estradiol + dydrogesterone]
- Sequential combined HRT (pill [Femoston - estradiol & dydrogesterone] or patch[FemSeven Sequi - estradiol + levonorgestrel) + progestogen-only contraception (tablet, implant, injection) : medroxyprogesterone / micronised progesterone / LEVONORGESTREL [mirena]
- If declines hormonal contraception: advise barrier methods with sequential combined HRT
Stop hormonal contraception at age 55yrs
What HRT if pt has a uterus and does not require contraception and has been amenorrhoeic for >1yr
Offer continuous combined HRT:
- Continuous combined pill [e.g. Femoston Conti - estradiol & dydrogesterone]
- Continuous combined patch [Femseven Conti - estradiol & levonorgestrel]
- Oestrogen-only pill [Bedol - estradiol]/ patch [Elleste Solo MX - estradiol] /gel [Oestragel - estradiol gel] with:
- IUS
- 5mg medroxyprogesterone acetate daily
- 100mg micronised progesterone daily
What HRT if pt has a uterus and does not require contraception and has not been amenorrhoeic for >1yr?
Offer sequential combined HRT:
- Sequential combined pill [Femoston - estradiol & dydrogesterone]
- Sequential combined patch [FemSeven Sequi - estradiol & levonorgestrel]
- Oestrogen-only pill [Bedol - estradiol]/ patch [Elleste Solo MX - estradiol] / gel [Oestragel] with:
- IUS
- 5mg medroxyprogesterone acetate daily
- 100mg micronised progesterone daily
What are the 2 main types of HRT and who are they for?
cyclical (sequential) = for women who are taking combined HRT but also still have their periods
- you take estrogen everyday and progestorone for 14 days every month or every 3 months (depending on how regular your periods are)
continuous combined HRT = for postmenopausal women
- you take oestrogen & progestorone every day
What do you do if a statin is suspected to be the cause of myopathy and CK conc is markedly elevated (> 5x the upper limit of normal)? or if muscular symptosm are severe
Discontinue treatment
If symptoms resolve, and CK levels return to normal, the statin should be reintroduced at a lower dose
Pt with catheter-associated urinary sepsis treated with ciprofloxacin.
How to best assess the beneficial effects of this treatment?
- blood culture 1 week after completion of Abx?
- check dipstick urinalysis for reduction of leucocytes & nitrites on completion of Abx?
- resolution of his acute symptoms over the next 72hrs
Resolution of symptoms
- as his infection is brought under control, his symptoms should resolve
[ dipstick tests are nearly always +ve because of long-term bacterial colonisation in pts with indwelling catheter ]
What routine blood monitoring is required for pts started on sertraline?
none
may cause hyponatraemia, and doses may need to be reduced in hepatic impairment, but no routine blood monitoring
What is the most appropriate monitoring option before starting treatment with amiodarone?
serum:
- calcium
- magnesium
- phosphate
- potassium
- sodium
K
hypokalaemai is a caution for amiodarone Rx and should be monitored (and corrected) prior to starting treatment
Best monitoring option to assess the beneficial effects of starting metoprolol for treatment of AF?
Heart rate
- main aim of BB therapy is AF control
[although ECG may be undertaken in assessment of AF, won’t give good measure of treatment effect]
Most likely drug to cause hypokalaemia?
- amlodipine
- atorvastatin
- indapamide
- metformin hydrochloride
- ramipril
indapamide
hypoK is a very common adverse effect of thiazide-like diuretics, including indapamide
Definition of syncope
& what is it NOT the same as?
Syncope may be defined as a transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery. Note how this definition excludes other causes of collapse such as epilepsy.
(NOT the same as postural hypotension or dizziness)
What contraception advice should be given to those on methotrexate?
Its highly teratogenic
Both men & women taking it should avoid conception while taking it and 6 motnhs afterwards
What electrolyte disturbance is a SE / risk of eplerenone?
Its a K-sparing diuretic, so hyperK is a primary risk
Serum K should be monitoed during initiation, esp in at-risk groups (elderly, CKD, DM)
i.e. telling GP to check serum K in 1 weeks time
What counts as a missed pill in contraception?
More than 24 hours late (not just 5 hrs)
If a pt misses her pill from the beginning of her pill cycle yesterday, and the second pill was due 5 hrs ago. Been sexually active last 3 days. Pill is COCP. what advice to give?
Take the pills for 1st and 2nd day now, resume normal pill taking for rest of cycle, and take subsequent 7-day pill-free break - she does not require additional contraceptive measures
Pt on warfarin is given clarithromycin for CAP in hospital.
INR 3.3 (target = 3.5) has mechanical heart valve, no macroscopic evidence of bleeding
what to do about warfarin?
continue at current does PO and recheck INR in 2 days
- her INR is in range for the indication (3-4 for mechanical heart valve)
- but still requires therapeutic monitoring because of the interacting clarithromycin, which can prolong the effects of warfarin –> rise in INR
- sufficient to recheck it in 48hrs
5-yr old boy brought to ED.
Fever, sore throat runny nose
pyrexial.
red throat, strawberry tongue, enlarged tonsils with no exudate, swollen neck lymph nodes. Blanching macular rash over his trunk, back, upper and lower limbs.
Given PCM PO, which allows him to maange oral fluid challenge.
Rx?
Phenoxymethylpenicillin 125 mg PO 6-hrly for 10 days
This is scarlet fever (macular red rash, strawberry tongue, red throad, fever >38). 10 day course according to HPE
What results on urine dipstick give a 92% positive predictive value for UTI?
positive for nitrite, leucocytes and blood
What are the recommended pre-meal blood glucose targets ? for type 1 and type 2?
type 1: 4-7
type 2: 4-7
what are the recommended post-meal blood glucose targets - type 1 and 2
Type 1 : <9
Type 2: <8.5
T1DM patient on biphasic insulin aspart (NovoMix30) 44 units SC at breakfast and 32 units SC with evening meals
Past 2 weeks pre-prandial and bedtime capillary blood glucose monitoring shows:
8: 6-9
12: 8-11
18: 16-22
22: 9-11
What to do?
Increase the breakfast biphasic insulin aspart (NovoMix 30) dose to 48 units SC
- because the intermediate release portion will kick in towards the end of the day
Her glycaemic control in the afternoon needs to be improved. Increase 08:00 dose by 10%
[increasing her evening one might cause hpoglycaemia in the morning]
What is biphasic insulin
Its a mixture of short or rapid-acting insulin with an intermediate acting insulin
Which drug should be continued through any intercurrent illness?
- salbutamol inhaled PRN?
- prednisolone 10mg PO OD
- losartan potassium
Prednisolone
Pt may have chronic adrenal suppression and steroid treatment must not be stopped abruptly
Select 3 prescriptions most likely to predispose to vaginal candida infection:
- amoxicillin
- beclometasone dipropionate 4oomcg inhated BD
- bendroflumethiazide
- clarithromycin
- losartan potassium
- prednisolone
- salbutamol
Prednisolone
- corticosteroids can predispose to candida but the systemic absorbtion from the beclometasone is inconsequential in comparison to oral pred
The Abx are much more likely to be the two other candidate drugs to contribute to her thrush
Select the 2 prescriptions that are most likely to be contributing to the exacerbation of her biventricular failure
- amoxicillin
- beclometasone dipropionate 4oomcg inhated BD
- diltiazem hydrochloride
- bendroflumethiazide
- clarithromycin
- losartan potassium
- prednisolone
- salbutamol
- Diltiazem
- Prednisolone
[corticosteroid and CCB]
- biventricular failure = CCF (which is a caution on prednisolone)
Which ONE prescription thati s CI in someone with ischaemic leg ulcers (likely PVD, no signs of critical ischaemia)
- aspirin
- atenolol
- atorvostatin
- ramipril
atenolol
Pt has probably peripheral vascular disease (PVD). B-blockers can cause Perihperal vasoconstriction and worsen ischaemia in PVD
[ACE-i are also cautioned in severe PVD, but this patient has no signs of critical ischaemia]
& its nifedipine, a CCB that is used to treat raynauds!
Features of an arterial ulcer
Occur on the toes and heel Painful There may be areas of gangrene Cold with no palpable pulses Low ABPI measurements
Pt is on sequential HRT, wishes to switch to a drug that will stop her monthly withdrawal bleeds.
DH:
Estradiol 50mcg/24 h transdermal patch and estradiol 50mcg / noresthisterone acetate 170mcg/24 transdermal patch combi (Evorel Sequi) one patch transdermally twice weekly for 2 years
Product containing both oestrogen and progestogen is required
Oestrogen will control the hormonal symptoms and progestogen is required as she has a uterus
Product that releases same dose continuously, rather than sequentially, will avoid WD bleeding
- i.e. switching to a continuous combined HRT
e.g. Estradiol 50 mictograms / norethisteone acetate 170 mcg / 24hrs transdermal twice weekly patch
or Levonorgestrel 7 mcg/ estradiol 50 mcg
How many mmol Na and CL in each 1 litre bag of 0.9% NaCl?
& what is the daily maintenance requirement of each ?
154 mmol each
1 mmol per kilogram
How many mmol potassium is required per day?
& how many mmol of K in 0.3% potassium chloride solution?
1 mmol per kilogram
Per litre, 40 mmol each of K+ and Cl- in a 0.3% solution of KCl
(this info is in the prescribing and dispensing information)
What do you need to aim for regarding plasma-glucose for someone who’s had a stroke?
Tight glycaemic control has not been shown to improve outcome in stroke and current recommendations suggest:
maintain a plasma glucose in the range 5 to 15 mmol/L
How to work out the appropriate rate of infusion of fluid for a 80kg man?
It is 25-30ml / kg / day
so…
2000-2400 mL / day (80-100mL/hr)
Check if they are euvolaemic or not..
Drug treatment for acute exacerbation COPD?
- Short-acting inhaled bronchodilator (NEB: Salbutamol) - maybe with ipratropium bromide?
- Prednisolone 30mg PO daily for 5 days [for all pts admitted to hospital with exacerbation of COPD]
- Aminophylline
- O2
- NIV
What drug to treat EPSEs of antipsychotics?
e.g. acute dystonic reactions
Procyclidine (an antimuscarinic)
Parenteral administraiton preferred over PO as may be unsafe swallow
Management of serotonin syndrome
IV fluids
benzodiazepines
severe: serotonin antagonists e.g. cyproheptadine and chlorpromazine
What to do if amiodarone and thyrotoxicosis?
withold amiodarone
major blood loss, shock, INR >10 (target 2.5)
withold warfarin
give dried prothrombin complex / FFP
& IV vit K
Post-op patient, on morphine MR 20mg PO 12-hourly
on day 2, develops oliguria despite fluid resus & becomes increasingly drowsy
Cr 232 (60-110)
a. continue the med
b. substitute fentanyl 25 mcg/h transdermal patch
c. substitute oxycodone 5mg PO 6-hourly for morphine sulphate MR
c.
oxycodone is metabolised by the liver to inactive metabolites, making it an appropriate option where strong analgesia is required in the setting of renal impairment
morphine is less appropriate in this context because, although also hepatically metabolised, one of its key metabolites is active and indeed more potent than morphine (morphine 6-glucuronide).
- its renally excreted and will therefore accumulate in renal impairment
most appropriate method to monitor adverse effects of apixiban in the first few months?
pt reports of bruising
- pts should report any bruising or other signs of bleeding immediately
[APTT is not a reliable test with factor Xa inhibitors].
whats the most appropriate monitoring option required before initiating azathioprine?
Thiopurine methyltransferase (TPMT)
at what BP should a COCP be stopped?
160/95 mmHg
1st line Rx for anti-psychotic-induced parkinsonism? esp symptoms of tremors?
Procyclidine hydrochloride 2.5 mg PO 8-hlry
SSRIs such as citalopram predispose to seretonin syndrome
name a drug that could precipitate this serious ADR
Tramadol
its a seretonin-inducing drug, could be given for lower back pain
What adverse effect is most likely to be caused by new initiation of Liraglutide?
- pancreatitis
- weight gain
- vom
Vomiting
- this GLP1 analogue frequently causes initial GI symptoms including N&V
If answer to calculation is 130.5 mL/h, should you round up?
NO!
just put full answer, unless it tells you otherwise
Someone started on ciclospirin for psoriasis, whats most important to tell them?
Regular monitoring of kidney function is required
- nephrotoxicity is a well-known adverse effect of ciclosporin therapy. RF measurements are required before starting. During, monitor serum CR every 2 weeks for first 3 months, then monthly
[its virtually non-myelotoxic - so reporting bruising / bleeding not that important]
instructions to communicate to pt regarding taking loperamide?
should be taken after each loose stool
Acute episode postherpetic neuralgia in elderly lady:
- presentation
- treatment of pain
shivering & myalgia combined with burning pain and numbness of skin on left side of her chest, rash in affected area
1st Line: paracetamol
2nd Line: amitriptyline (/duloxetine / gaba / pregaba)
- SEs: anticholinergic
DKA T1DM, currently takes :
- soluble insulin 10-12 units SC TDS with meals
- insulin glargine 24 units SC nightly
is recieving IV fluid resus
what to do regarding his hypoglycaemic meds ?
- stop soluble insulin
- continue insulin glargine
- start fixed-rate IV insulin infusion (required along fluid resus)
Rx for repeated C. diff infections?
oral vancomycin
where first-line therapy with metronidazole has failed or is not tolerated
Treatment for vulvovaginal candidiasis in preganancy?
Clotrimazole pessary 100 mg PV daily for 7 days
- prolonger therapy is advised for candidal infection in pregnancy
- systemic therapy is not recommended in pregnancy
a. 2 medications most likely to cause ankle swelling
b. 2 medications most likely to be causing bradycardia
- amlodipine
- bisoprolol
- digoxin
- lisinopril
- naproxen
- warfarin
a. Amlodipine & naproxen
- naproxen can also cause ankle oedema
b. Bisoprolol & digoxin
- BBs commonly cause brady
- Digoxin can cause lots of rhythm disturbances including bradycardia, particularly if the dose is too high
What are 2 medications that cause dyspepsia?
Prednisolone :
Alendronic acid : direct irritant to the upper GI tract, and symptoms are not improved by PPIs
What are 2 meds that cause diarrhoea?
alendronic acid : can cause diarrhoea
lansoprazole: & all PPIs can cause loose stools and diarrhoea
what is the maximum dose of citalopram in the elderly?
20 mg daily
whats the K+ sparing diuretic beginning with E?
Eplerenone
Who is metformin CI’d as a first line treatment for T2DM?
- low/normal weight
or
- creatinine >150 umol
what should you give for someone dehydrated and shocked?
500mL sodium chloride 0.9% solution over 15 mins
what causes shingles?
varicella zoster virus
(& chicken pox)
[dose of aciclovir is higher than herpes simplex]
what causes genital and oral herpes?
Herpes simplex virus
Cautions for the use of metoclopramide
- cardiac conduction disorders (e.g. QTc - QT interval long)
- electrolyte disturbances that are uncorrected
[ extra pyramidal effects are also common and will be greater risk for pts taking an antipsychotic ]
–> use cyclizine instead if pts at risk of EPSE and QT prolongation
