OSCEs Flashcards
You may be asked about a scenario when potassium chloride concentrate is being used to prepare an infusion. What is the risk here, and what can be done to minimise this risk?
Potassium overdose can be fatal due to cardiac toxicity
Ideally ready mixed infusion solutions should be used, but if potassium chloride concentrate must be used then the infusion must be MIXED THOROUGHLY
Make sure you check the patients potassium level before therapy and throughout
Check renal function- avoid if severe
Concentrated vials should not be mixed with less then 50X its volume of SODIUM CHLORIDE 0.9%
MIX WELL
so one 10ml vial (containing 20mmol K+) should be mixed with 500mL NaCl 0.9%, 2 vials would be mixed with 1000ml etc.
The concentration should not normally exceed 40mml/L when given PERIPHERALLY (ask what line)
The infusion should be given SLOWLY over 2-3 hours
ECG monitoring should be carried out
Advise on importance of selecting the correct strength.
Spironolactone OR co-amilofruse (amiloride and furosemide) OR Furosemide
Which one has the most evidence for use in Heart Failure?
Spironolactone has better evidence for HF- RALES trial
Fine to manage with IV Furosemide as an inpatient
However recommend switching to PO spironolactone on discharge- check renal function as avoided in AKI/ severe impairment
When completing a drug history you note that a patient on warfarin buys St Johns Wort OTC. What is the problem here?
You also note this patient takes OTC ibuprofen for gout. What do you recommend?
St Johns Wort decreases the anticoagulant affect of warfarin- advise against concomitant use
Ibuprofen should not be taken: warfarin is predicted to increase the risk of bleeding events when given with Ibuprofen. Manufacturer advises use with caution or avoid- avoid all NSAIDs for gout management
Instead, use oral colchicine to manage acute attacks of gout, and can use allopurinol for prophylaxis
A patient is admitted to hospital for acute asthma exacerbation. He has had two previous admission for asthma that year.
He is prescribed prednisolone 40mg OD for 5 days then to stop
Discuss
Find out if the patient received steroids during his last admissions/ at any other point that year
If so, the steroid should be weaned down not stopped abruptly as tapering the drug gives the adrenal glands time to return to their normal patterns of secretion. If this is not done, prednisone withdrawal symptoms may present: Severe fatigue. Weakness.
Can reduce to 30mg after 1 week, then 20mg, then 10mg after another week then 5mg then stop. Ensure patient is counselled and a steroid card is given.
Think about the bigger picture-
Why have they been admitted frequently?
Assess inhaler technique and understanding of different uses of different inhalers
Determine what step they are in the BTS guidelines: recently changed- now everyone at STEP 1 needs both reliever and preventer therapy
What questions need to be asked when taking a drug history?
ALLERGIES? Regular meds? Herbal meds? OTC meds? creams/ ointments? Ear/eye/nose drops? Inhalers? Alcohol status? Smoking status?
Ensure you ask ALL of these, 1 mark for each, plus 1 mark for DOCUMENTING each as a pharmaceutical issue
What medications do we normally see used in HEART FAILURE?
ACE inhibitors
Beta blockers offered to all patients with HF due to left ventricular systolic dysfunction
Can add in an ARB or an aldosterone antagonist such as SPIRONOLACTONE (best evidence- RALES trial) if ACEi + beta blocker ineffective. If Spironolactone used with ACE/ARB- monitor potassium as both can cause hyperkaleamia
Can consider Hydralazine in combination with a nitrate (e.g. isosorbide mononitrate) especially if patient is Afro Carribean
Adjunct therapy to consider:
Ischeamic Heart Disease management risk-
> Aspirin
> Statin
?Digoxin for severe HF with LVSD
How should an ACE inhibitor be initiated?
Baseline Blood Pressure and U&E’s before initiation
Check BP and U&E’s within 2 weeks after initiation or change of dose, then annually
If renal function deteriorates, stop ACEi- don’t stop if only a small rise though (e.g. Cr 99 goes to 110). Look at eGFR- max. initial dose 1.25 mg once daily if eGFR <30.
Cough is not an indication for drug withdrawal
Why are NSAIDs avoided in patients with Heart Failure?
NSAIDs can cause sodium retention and vasoconstriction
They can cause Kidney injury
They can reduce effectiveness and increase toxicity of ACE inhibitors and diuretics (through kidney injury?)
Recent findings suggest higher risk of CV events in patients on NSAIDs
You receive a medicines information query regarding the compatibility of amphotericin B and potassium infusion runnning together. What two resources could you use to answer this enquiry?
Handbook of Injectable drugs (trissell)
UCLH Injectable Medicines Administration Guide
You receive a medicines information query regarding the compatibility of amphotericin B and potassium infusion runnning together.
Potassium is already running down a peripheral line but patient needs a dose of Amphotericin now.
What MI questions would you ask? Try and think of 8 points you need to note.
Enquirer details:
Name, role
Contact details
When is the answer needed
Patient details:
Name, hospital number, DOB, weight, height, allergy status, PMH, PC
What other drugs is the patient on?
What lines does the patient have in place?
Why is amphotericin to be used? Indication? Micro approval?
Dose of amphotericin is usually based on WEIGHT so ensure you ask weight
Blood results- creatinine, LFT’s, POTASSIUM level
Amphotericin can potentiate hypokaleamia
Why may two drugs not be compatible?
Solubility
Interactions
pH
Stability? Crystalisation?
What could happen if two drugs are incompatible and run down the same line?
decreased drug effectiveness/ treatment failure
increase the risk for adverse effects such as injection site reactions
What drugs pose a risk for patients with GI bleeding and should be used with caution/ discontinued?
Aspirin / NSAIDs- stop in patients with peptic ulcer bleeding
SSRI’s- use with caution
Use with caution:
Oral anticoagulants
Steroids
Treatment of G2 reflux oesophagititis involves an 8 week course of omeprazole 20mg OD.
What lifestyle advice would you offer to someone with oesophagitis?
Eat smaller more frequent meals- leave at least 3 hours after eating before going to bed
Raise one end of the bed so that chest and head are above waist level
Have a healthy balanced diet- aim to lose weight
Avoid food or drink that triggers it
Don’t smoke
Decrease alcohol intake
What does treatment for H.pylori involve?
Hint: Triple therapy involving 1 PPI + 2 AB’s
Omeprazole 20 mg BD + clarithromycin 500 mg BD + amoxicillin 1,000 mg BD for one week
OR if penicillin allergy:
Omeprazole 20 mg BD + clarithromycin 250 mg (alternatively 500 mg) BD + metronidazole 400 mg BD for one week
Lifestyle advice!!!:
Recommend avoiding foods, beverages, and drugs that increase the production of stomach acid, since acid can hinder the treatment process.
Cigarettes, aspirin, naproxen, ibuprofen, alcohol, and caffeine can worsen symptoms, as can spicy foods.
Stop smoking and cut down alcohol!!!!
Need to avoid alcohol especially if taking metronidazole- interaction!
What five pointers would a post- surgical treatment plan involve?
VTE prophylaxis- reduced mobility post surgery- check notes from surgeons, consider choice according to patients renal function. Check platelets before initiation- and monitor due to risk of HIT developing.
Antiemetics for post op N&V
Pain control- opioids to start then stepping down the pain ladder
Antibiotics
Laxatives- especially if on opioids
Counsel a patient newly started on Rivaroxaban.
The patient has AF and has been started on Rivaroxaban for prevention of stroke.
Please see counselling sheet in revision notes and ensure all points are covered.
You are asked to write up a treatment plan for a patient withdrawing from alcohol in their medical notes. The guideline is given to you. What basic info should you start with when making a medical entry and what three drugs are you likely to mention?
Medical note entry: Patient name Hospital number DOB 'Pharmacist Entry' Signature, name, bleep
Chlordiazepoxide: PRN (25-50mg 2 hourly for first 24 hours, no more than 300mg per day, 2 hourly monitoring as per CIWA
Then reducing regimen over 2-5 days
Use Lorazepam if evidence of liver impairment!!
Pabrinex- treatment dose or prophylaxis- monitor for anaphylaxis reaction, give as IV infusion over 30 mins, then step down to oral thiamine and vitamin B co strong.
Lactulose 30-50ml TDS- ensure bowels open to prevent hepatic encephalitis
Also consider anticoagulation- dependent on clotting factors and liver function
A patient with a history of previous DVT is due to undergo surgery next week and you are asked by the doctor how to go about bridging with Enoxaparin. What questions do you ask and monitoring requirements, and what does the usual bridging scenario involve PRE-surgery (no need to talk about post just yet) ?
When was the patients DVT? Determine whether they are very high risk- if so they would need to be admitted for a UFH infusion 3 days before surgery.
high risk- stop warfarin 5 days before and start TREATMENT dose enoxaparin (1.5mg/Kg), stop 24 hours before surgery
Medium risk- stop warfarin 5 days before and start PROPHYLACTIC dose
Low risk: stop warfarin 5 days before surgery, give vitamin K by mouth the day before surgery if INR is over 1.5 (blood too thin)
Monitoring: CrCl Platelets K+ Weight
How should we go about managing a patient usually on warfarin bridged with Enoxaparin prior to surgery in the POST operative phase?
Bleed risk needs to be assessed.
Those that are high bleed risk: restart warfarin 48 hours after surgery.
Low risk: restart warfarin imminently.
Reload dependent on INR and as per Trust guidelines:
e.g. GSTT: restart with a loading dose of 1.5 x patient’s usual dose for 3 days, then continue on usual dose. Continue treatment dose enoxaparin until INR is in therapeutic range for 2 consecutive days. Monitor INR daily. Monitor LFT’s for warfarin. Monitor for signs of bleeding
Which antiemetic(s) should be avoided in patients with Parkinsons and why? Which is a safe alternative?
Metoclopramide
Prochlorperazine
These are dopamine antagonists. They therefore worsen parkinsons symptoms- Extrapyridamidal symptoms such as Tardive Dyskinesia, Dystonia, Tremor)
Domperidone is the drug of choice. It is a dopamine antagonist but it doesn’t cross the Blood Brain Barrier. 10-20mg TDS. It prolongs QT interval so be wary with other QT prolonging drugs (monitor)
You are taking in an enquiry regarding how to administer pramiprexole down an NG tube. Take in this enquiry, ask all relevant questions so that someone else would be able to pick this up with the information you obtain. What resources could you use?
Enquirer details: Name, job role, contact number, how long until you need an answer?
Patient details: Name, DOB, ward, hospital number, allergy status, weight, height
Past medical history? Presenting complaint?
Indication for pramiprexole, dose, current route, next dose due?
Reason for NG tube?
Other medication?
Type of tube?
How long are the expected to require this?
Are any feeds being given down the tube?
What other drugs are going down the tube?
Start with BNF, SPC, Martindale
More specific: Handbook of Drug administration via Enteral Tubes
NEWT guidelines
Re station involving a treatment plan for a patient withdrawing from alcohol. How is Pabrinex infused?
Pabrinex Intravenous High Potency Concentrate for Solution for Infusion should be administered by drip infusion. NB: there is also Pabrinex Intramuscular High Potency Injection- make sure you are talking about the right ampoules.
Usual Tx of Wernicks Encephalopathy= 2 or 3 pairs TDS
Equal volumes of the contents of ampoules number 1 and 2 (ampoule 1 and 2 constitute a pair of ampoules) should be added to 50 ml to 100 ml NaCl 0.9% or 5% glucose and infused over 30 minutes Intavenously
1 ampoule= 5ml
So, if treatment of Wernicks Encephalopathy= 2 or 3 pairs TDS (8 hourly)
that means 2 or 3 x ampoule 1 (5ml)= 10-15ml
Plus 2 or 3 x ampoule 2 (5ml)= 10-15ml
NOTE: Pabrinex Infusions can cause ANAPHYLACTIC SHOCK- monitor patient closely, ensure its infused over 30 minutes to minimize risk of anaphylaxis and ensure correct medicines are prescribed PRN to treat- adrenaline, chlorphenamine, hydrocortisone
If a patient is admitted with an exacerbation of, say Heart Failure, or Asthma, or COPD, what sort of questions should we be asking?
We need to explore medicines compliance in these scenarios
So, ask about missed doses of their regular medication, check understanding of why each medication is being used, ensure they understand the importance of taking correctly to avoid further admissions in the future.
Explore whether they are worried about side effects? Are you having trouble remembering to take all of your tablets?
You have a patient with gout also taking bendroflumethiazide for hypertention, the patient suffers from HTN, diabetes and gout. What is the issue?
Bendroflumethiazide may raise serum uric acid levels with consequent exacerbation of gout in susceptible patients.
Bendro may also worsen diabetes. Care is required when bendroflumethiazide is administered to patients with a known predisposition to diabetes.
If a parkinsons patient comes in with a sudden change of behaviour, what should you do?
You should request for the parkinsons team to review their medication, as Levodopa can cause changes in behaviour such as compulsion.
With patients in the OSCEs on IV antibiotics- what questions should immediately come into your head?
ALLERGIES?
INDICATION? EMPIRICAL? CULTURES+SENSITIVITES REQUESTED IF SO? MICRO INVOLVEMENT PLANNED?
REVIEW DATE?
INFLAMMATORY MARKERS? IV to ORAL SWITCH POSSIBLE?
The BTS management of asthma guidelines were updated in September 2016. What does the new STEP 1 involve, and can you give an example of the inhaler/ doses? When should you consider stepping up?
STEP 1:
Regular preventer therapy using a low dose inhaled corticosteroid
+
salbutamol (SABA) PRN
Examples of low dose ICS:
Beclomethasone dipropionate 100 micrograms two puffs twice a day/ Branded= Clenil Modulite
QVAR 50 micrograms two
puffs twice a day
Step up: if using three doses a week or more of salbutamol inhaler
What does STEP 2 of the BTS management of asthma guidelines involve?
Addition of an inhaler Long Acting Beta 2 agonist to regular low dose corticosteroid therapy.
e.g.
Beclometasone dipropionate (extrafine) with formoterol- Fostair (NEXThaler) 100/6 one puff twice a day
In the new BTS guidelines, what is equivalent to medium dose ICS and what step is this?
Beclomethasone 200 micrograms two
puffs twice a day
Consider at step 3 after addition of LABA to low dose ICS has failed to adequately control asthma
At step 3 of the asthma BTS guidelines, there is an option to add in a Leukotriene Receptor Antagonist, a LAMA or Slow release Theophylline. What is a LTRA and what is a LAMA?
LTRA= Montelukast
LAMA= long acting muscarinic antagonist e.g. Tiotropium in SPIRIVA RESPIMAT- 5 micrograms ONCE daily
What is the problem with phenytoin and Enteral feeds?
They interact
Enteral feeding (interrupt feeding for 2 hours before and after dose; more frequent monitoring may be necessary). Remember, phenytoin is highly protein bound, therefore any protein in the feed with bind to phenytoin and affect its pharmacokinetics
What monitoring parameters should be advised for administration of IV phenytoin? Use BNF to advise on how to give (hint: requires an in-line filter)
IV phenytoin must be administered slowly
Dilute to a concentration not exceeding 10 mg/mL with Sodium Chloride 0.9% and give into a large vein through an in-line filter. Give at a rate not exceeding 1 mg/kg/minute
ECG monitoring and Blood Pressure monitoring is essential
Monitoring of levels: target = 10-20 mg/l
Monitor for symptoms of phenytoin toxicity: nystagmus, diplopia, slurred speech, ataxia, confusion, and hyperglycaemia.
In pregnancy, the elderly, and certain disease states where protein binding may be reduced- more appropriate to measure free plasma-phenytoin concentration.
Counsel a patient newly started on Methotrexate 7.5mg Once a week for Rheumatoid Arthritis.
Hint: they were given a methotrexate patient booklet by their doctor
See MTX counselling sheet in revision notes
Talk me through the different steps of the asthma guidelines (can use printout in notes)
See/ talk through steps in notes
If asked to take in an MI enquiry about administration of drugs IV, what sort of questions (on top of the normal questions) should you be asking?
What infusion fluid is prescribed?
What volume of infusion fluid is prescribed?
What rate is prescribed?
What type of IV access does the patient have? Other access routes they have available?
Are any other drugs being given IV?
Central or peripheral?
What three questions should you ask if receiving an enquiry about enteral feeding tubes?
Type of tube
Where is the end of the tube
Are they on any feeds?
Are any other drugs going down the tube?
How long are they expected to have the tube?
What questions would you ask if taking in an MI enquiry about a drug interaction?
See Mi guide in notes
What questions would you ask if taking in an MI enquiry about the use of a drug in pregnancy?
See Mi guide in notes
What questions would you ask if taking in an MI enquiry about the use of a drug in breastfeeding?
See Mi guide in notes
If a patient is on PCA, what drug must you always make sure is prescribed PRN?
NALOXONE- check this if patient is on PCA in the OSCE’s
Take a look at your notes on how to initiate warfarin
How should INR be monitored during the initiation phase?
Every 2 – 3 days - Until INR within therapeutic range on 2 consecutive INR checks
Then every week- Until INR within therapeutic range on 2 consecutive INR checks
Then every 2 weeks- Until INR within therapeutic range on 2 consecutive INR checks
Then every 4 weeks
What should be used to manage patients with major peptic ulcer bleeding?
High-dose intravenous PPI therapy (e.g. omeprazole or pantoprazole 80mg bolus followed by 8mg/hour infusion for 72 hours) should be used in patients with major peptic ulcer bleeding
Give info on how to give infusions from BNF
Then oral stepdown- look up!!
What is the first thing you should do if a doctor asks you to advise him on the next step of the asthma guidelines or COPD guidelines?
check patient compliance and inhaler technique before considering any step up in the guidelines!
Suggest adding a spacer to improve inhaler technique
What markers would indicate an exacerbation of COPD?
Inflammatory markers up: C-reactive protein, , WBC, fibrinogen and leukocytes
elevated hematocrit
Arterial blood gases: pH, arterial carbon dioxide tension, arterial oxygen tension, bicarbonate
Also do: chest X-ray, ECG
How do we titrate doses of beta blockers?
Start low and go slow- start at a low dose e.g. bisoprolol 1.25mg OD and titrate slowly over a period of weeks or months
When starting Ace inhibitors or Spironolactone in Heart Failure patients, what monitoring should we advise?
Serum Creatinine
eGFR
Potassium
A patient with Heart Failure is fluid overloaded and you need to recommend a diuretic. Their eGFR is 25ml/min.
What do you recommend?
A LOOP diuretic- furosemide
NOT a thiazide diuretic- this are ineffective for patients with eGFR<30ml/min.
Could recommend potassium sparing diuretic- spironolactone (high dose of 100mg OD for oedema in congestive HF). Used at a much lower dose of 25mg - 50mg OD when used as an adjunct in moderate/severe HF.
What renal condition must ACE inhibitors / ARB’s be avoided in?
Severe bilateral renal artery stenosis- ACE inhibitors reduce or abolish glomerular filtration, and are likely to cause severe and progressive renal failure.
Previous OSCE: MI enquiry, does sodium valproate cause neutropenia. If you asked all the right questions i.e. is the patient on any other medication, is there a particular reason you think its sodium valproate causing the neutropenia, have any of his other drugs been started recently, you would have established that the patient started on Carbimazole 3 weeks ago and this was the cause of the neutropenia.
If you get an MI enquiry asking whether X drug causes Y side effect, ensure you do some digging as its likely its a different one of the patients drugs causing it, they just want to make sure you’re asking the right questions to establish this!
Potassium chloride may be given at a max concentration of 40mmol/L when given by PERIPHERAL intravenous infusion
You can go stronger than this through a central line, but this requires ICU admission and very specialist monitoring of ECG
A doctor asks you how to increase the dose of phenytoin in one of his patients. He said that he has checked levels and they have been sub-therapeutic for some time. (latest level= 8mg/L). After further reporting you note that the patients albumin level has also been low for some time. What do you do?
Phenytoin is highly protein bound
Therefore if albumin is low, the level of phenytoin will show to be low, but this is not a true reflection of the actual plasma levels
Suggest he does a free phenytoin (unbound fraction) level and continue to monitor this way
Phenytoin has ZERO order kinetics, which means a small change in dose can lead to massive changes in concentration.
This means you should never titrate up too quickly:
50mg Increments for doses between 200-400mg
100mg increments for doses above 400mg
This is not in the BNF, so remember this advice!
Counsel me on using an accuhaler
See notes
Counsel me on using a pMDI
Then counsel on using a spacer too
See notes
