Pass the PSA Flashcards
What are the commonest enzyme inducers?
PC BRAS
Phenytoin Carbamazepine Barbituates Rifampicin Alcohol (chronic excess) Sulphonylureas
What are the most common enzyme inhibitors?
AO DEVICES
Allopurinol Omeprazole Disulfaram Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute) Sulphonamides
Which long term drug should be increased in surgery?
Steroids
Which drugs should be stopped before surgery?
I LACK OP
Insulin Lithium Anticoagulants COCP K sparing diuretics Oral hypoglycaemic Perindopril and other ACEis
What are the contraindications to drugs which increase bleeding?
Those who are bleeding
Those who might be bleeding
Those who are at risk of bleeding (e.g. liver failure)
Should prophylactic heparin be given to an acute ischaemic stroke patient?
No - because it risks bleeding into the stroke causing haemorrhagic transformation
What are the contraindications to steroid use?
Remember the side effects - STEROIDS
Stomach ulcers Thin skin oEdema Right and left heart failure Osteoporosis Infection Diabetes Syndrome of Cushing..
What are the contraindications to NSAID use?
NSAID
No urine (i.e. renal failure) Systolic dysfunction (heart failure) Asthma Indigestion Dysgrasia (abnormal clotting)
What are the contraindications to antihypertensive use?
Hypotension
Bradycardia if beta blockers and CCB
Electrolyte disturbances if ACEi and diuretics
What are the side effects of ABCD antihypertensives?
ACEi - dry cough, angioedema
Beta blockers - wheeze, worsens acute HF
CCB - peripheral oedema, flushing
Diuretics - renal failure, (loop -> gout, K sparers -> gynaecomastia)
What is the maximum rate at which IV potassium can be delivered?
10mmol/hr
When might you give 5% dextrose over 0.9% saline?
Hypernatraemia
Hypoglycaemia
When would you give gelofusine over 0.9% saline?
If systolic BP <90
Which three parameters should be assessed to determine fluid response and future dosing?
BP
HR
Urine output
What is the definition of oliguria and what does it mean for the patient’s fluid balance?
<30ml/hr
Means they are 500ml dry
What fluid prescription should be given fro someone who is dehydrated with tachycardia or hypotension?
500ml bolus or 250 in HF
How much maintenance fluids do adults need?
3L/24hrs - 8 hourly bags
2L/24hrs if elderly - 12 hourly bags
How much potassium should be given daily for maintenance?
Provided not in renal failure
We need 40mmol/day
Therefore put 20mmol in 2 bags each day
What are the common antiemetic doses?
Cyclizine - 50mg 8 hourly IM/IV/PO
Metoclopramide - 10mg 8 hourly IM/IV/PO
Use metoclopromide over cyclizine in HF as the latter causes fluid retention
When should you not use metoclopramide?
Parkinson’s patients
What is a typical codeine dose for mild/moderate pain?
30mg up to 6 hourly oral
What is a typical co-codamol dose for severe pain?
Co-codamol 30/500, 2 tablets 6 hourly PO
What is the prescription for neuropathic pain?
Amitryptiline 10mg PO ON
Pregabalin 75mg PO 12hrly
Duloxetine 60mg PO OD
What effect do thiazide diuretics have on potassium levels?
Causes hypokalaemia
Other than anti-emesis, what property does cyclizine have?
Anti-histamine
What should be done for a patient on methotrexate with a UTI?
Withold the methotrexate (if septic) and prescribe nitrofurantoin (NOT trimethoprim)
Which antihypertensive commonly causes peripheral oedema?
CCBs
How would you manage a patient with bradycardia and peripheral oedema on verapamil and bisoprolol?
And why?
Stop the verapamil:
1) NEVER give verapamil to a patient already on beta blockers
2) CCBs cause peripheral oedema, so stop verapamil rather than adding furosemide
3) Don’t stop 2 rate controllers at the same time as it would likely cause a rebound tachy
What is Novomix and by which route is it administered?
A mixture of short and medium acting insulin given SC
For how long following stroke should prophylactic enoxaparin be held?
2 months
What is a typical dose of bisoprolol?
10mg OD PO
What are the causes of hypernatraemia?
Dehydration
Drip - excess saline?
Drugs - particularly effervescent/iv preparations
Which drugs might cause a thrombocytopenia?
Penicillamine
Heparin
What are causes of hypokalaemia?
DIRE
Drugs - Thiazides, loops
Inadequate intake/excess loss
Renal tubular acidosis
Endo - Cushings and Conns
What are the causes of hyperkalaemia?
DREAD
Drugs - ACEi, ARBs Renal failure Endocrine - Addison's Artefact DKA
In which type of AKI is urea raised more than creatinine is?
Pre-renal
When and how should Vitamin K be given to a warfarin patient?
Give as oral if INR>8 without bleeding
Give IV if any major or minor bleeding alongside PCC
What type of drug is Bumetanide and when is it used?
A loop diuretic used in patients resistant to furosemide
Which drugs are used for rate control in fast AF, and when would you not use each of them?
Bisoprolol - asthmatics
Diltiazem - fluid overload
Digoxin
Management of STEMI?
Abcde O2 aiming for 94-98% 300mg aspirin 5mg IV morphine 10mg IV metoclopramide GTN spray/tablet Beta blockers unless brady/asthmatic/CCF Primary PCI or Alteplase Transfer to CCU
NSTEMI management?
Abcde O2 aiming 94-98% 300mg aspirin 5mg IV morphine 10mg IV metoclopramide GTN Clopidogrel 300mg and LMWH Beta blocker unless CI CCU transfer
Acute heart failure management?
ABCDE Sit up O2 aiming 94-98% 5mg IV morphine 10mg IV metoclopramide GTN spray/tablet Furosemide 40mg IV Isosorbide infusion if furosemide ineffective CPAP if above fails CCU transfer
Anaphylaxis management?
ABCDE O2 high flow Remove the cause ASAP Adrenaline 500mcg of 1:1000 10mg IV Chlorphenamine 200mg IV Hydrocortisone Asthma Rx if wheezy
Acute asthma management?
ABCDE 100% O2 Salbutamol 5mg NEB Hydrocortisone 100mg IV (if severe/LT), 50mg PO pred if moderate Ipratropium 500mcg NEB Theophyline if LT
PE management?
ABCDE High flow O2 5mg morph 10mg meto IV LMWH e.g. Tinzaparin SC (Rx dose) If hypotensive -> IV gelofusine -> noradrenaline -> thrombolysis
GI bleed management?
ABCDE 15L O2 2 large bore cannulae Catheter Fluids (crystalloid) Cross match 6 units Correct clotting abnormalities (FFP or PTC if on warfarin) Endoscopy + terlipressin + banding Stop aspirin, warfarin etc Call surgeons if needed
Bacterial meningitis management?
A-E O2 IV fluids Dexamethasone IV CT head -> LP 2g cefotaxime Conider ITU
Status epileptics management?
A-E O2 Recovery position Lorazepam IV/buccal midazolam Repeat after 5 mins Call anaesthetics Phenytoin/phenobarbitone infusion Rapid sequence induction (propofol/sodium thiopental)
Acute ischaemic stroke management?
A-E Investigations - glucose, CT head 300mg Aspirin once haemorrhage excluded Thrombolysis if <4.5hrs Thrombectomy if <6 hours Stroke unit transfer
DKA management?
A-E
IV fluid replacement (generally bolus ->maintenance) with KCl unless anuric
Insulin IV 0.1U/kg/hr
Monitor everything
Once BM<14 - start 10% dextrose at 125ml/hr + NaCl
Continue IV insulin till patient able to eat/drink, bridge with SC insulin for 1 hour before stopping infusion
AKI management?
A-E Cannulate and catheterise Fluid monitoring 500ml bolus STAT 1L 4 hourly Investigate cause and comps
What are the components of the CHA2DS2-VASc score?
Congestive heart failure Hypertension Age >75 (2pts) Diabetes Stroke/TIA (2pts) Vascular disease Age 65-74 Sex (female)
0 - 75 aspirin OD
1 - aspirin or warfarin
2 or more - Warfarin (target INR 2.5)
Chronic asthma mangagement protocol?
- SABA PRN
- Add 400mcg steroid INH
- Add LABA, assess response and adjust dose, if no response -> stop and up steroid dose
- Consider LTRA or upping steroid dose further
- Steroid tablets
Name one of each of the following:
Stool softener
Bulking agent
Stimulant laxative
Osmotic laxative
Stool softener - Docusate sodium
Bulking agent - Isphagula husk
Stimulant laxative - Senna, Bisacodyl
Osmotic laxative - Lactulose, phosphate enema
What is the first line management of PD?
Co-careldopa (Levodopa + dopa decarboxylase inhibitor
What might be used instead of co-careldopa in first line management of mild PD?
Dopamine agonist e.g. Ropinirole
MAO-A inhibitors - Rasgiline
What are the side effects of Lamotrigine?
Rash
Sometimes SJS
What are the side effects of Carbamazepine?
Rash Hyponatraemia Dyarthria Ataxia Nystagmus
What are the side effects of Phenytoin?
Peripheral neuropathy
Gum hypertrophy
Hepatotoxicity
Ataxia
What ar the side effects of valproate?
Tremor
Teratogenicity
Weight gain
How would you induce remission in a mild and severe Crohns flare?
Mild - 30mg PO Prednisolone
Severe - 100mg IV Hydrocortisone
How would you maintain remission in Crohns?
Azathioprine or 6-mercaptopurine
Check TPMT first
What is the management of rheumatoid arthritis?
Start Methotrexate and a DMARD (sulfasalazine/hydroxychloroquine) ASAP
During a flare:
Short term IM methylpred
Short term Ibuprofen with lansoprasole
Aside from being a sedating antihistamine used as an antiemetic, what other side effects might cyclizine cause?
Anti-muscarinics (urine retention, constipation, dry mouth etc)
What is hydroxycobalamin used for?
B12 deficiency
Which two anti-emetics are not safe for use in PD?
Metoclopramide
Haloperidol
Which antiemetic does not cross the BBB, and is those particularly safe in PD?
Domperidone
Which anti-diabetic drug confers risk of lactic acidosis?
Metformin
Do sulphonylureas (e.g. gliclazide) confer risk of hypoglycaemic episodes?
Yes
How frequently is methotrexate taken by RA patients?
Weekly
What medication should be co-prescribed with methotrexate?
Folic acid
What should be done on commencement of steroid therapy in someone likely to be on the medication for more than 3 months?
Co-prescribe bisphosphonates due to osteoporosis risk
How much of a drug in 1% solution is in:
100ml
1ml
100ml = 1g 1ml = 10mg
What is the treatment dose of Dalteparin and Enoxaparin?
Dalteparin = 15000 units Enoxaparin = 12000 units
What is the starting dose of Ramipril for symptomatic HF?
1.25mg
What time of day should ACEi be taken?
18:00 (ON)
What is the prescription for insulin in hyperkalaemia?
Actrapid
IV
10 units in 100ml of 5% dextrose over 30 mins
What must you measure before starting a patient on vancomycin and why?
UnE (Cr clearance) - as vancomycin is renally excreted
Which blood test should be done before starting a patient on a statin?
LFT - statins are metabolised by the liver.
What blood tests must be done before starting methotrexate?
FBC
LFT
UnE
HcG
WHat is a contraindication to methotrexate use (other than pregnancy)
Deranged LFTs due to risk of cirrhosis
What effect does sodium depletion have on lithium levels?
Causes them to rise.
What should be monitored in patients on digoxin?
UnEs/serum Creatinine
Common ADRs to Gentamicin and Vancomycin?
Nephrotoxicity
Ototoxicity
Common ADRs to all antibiotics?
C dif colitis
Common ADRs to ACEis>
Hyperkalaemia
Dry cough
Hypotension
Common ADRs to B blockers
Bradycardia
Wheeze in asthmatics
Worsens acute heart failure
Fatigue
Common ADRs to CCBs?
Peripheral oedema
FLushing
Bradycardia
Common ADRs to heparin?
Haemorrhage
Thrombocytopaenia
Common ADRs to warfarin?
Haemorrhage
Common ADRs to aspirin?
Haemorrhage
Gastritis/PUD
Common ADRs to digoxin?
N/V/D
Blurred vision
Common ADRs to amiodarone?
Interstitial lung disease
Thyroid disease
Grey skin
Thrombophlebitis
Common ADRs to Lithium?
Early tremor
Intermediate tiredness
Late arrhythmias, seizures, coma, renal failure, DI
Common ADRs to haloperidol?
Dyskinesia
Common ADRs to Dex and Pred?
STEROIDS
Stomach ulcers Thin skin Edema Right and left HF Osteoporosis Infection Diabetes Syndrome of Cushing
Common ADRs to statins?
Myalgia
Abdo pain
LFT derangement
Rhabdomyolysis
What class of drug is amiloride, and what biochemical side effect does it commonly have?
Potassium sparing diuretic commonly associated with Hyperkalaemia
What should be given to a conscious and alert patient who is hypoglycaemic?
10-20g of glucose
Which of the following drugs should be stopped before surgery?
Metformin Microgynon Enoxaparin Aspirin Bisoprolol Novomix 30 Paracetamol Lansoprazole
Metformin Microgynon Enoxaparin Aspirin Novomix
By how much should steroids be increased in long term users who are acutely unwell?
Double the dose
What drug would you give for the immediate relief of dyspepsia?
10ml PO Magnesium carbonate (antacid)
What is the main contraindication to lactulose use?
Bloating
What is the first line management of GAD?
Citalopram NOT Propranolol