Pass the PSA book notes Flashcards
Which common drugs are enzyme inducers?
PC BRAS: Phenytoin Carbamazepine Barbituates Rifampacin Alcohol Sulphonylureas
Which common drugs are enzyme inhibitors?
AO DEVICES: Allopurinol Omeprazole Disulfiram Erythromycin Valporate Isoniazid Ciprofloxacin Ethanol Sulphonamide
Which common drugs should be stopped before surgery?
I LACK OP
Insulin Lithium Anticoagulants COCP/ HRT K-sparing diuretics Oral hypoglycaemics Perindopril and other ACE-i
What are the rules regarding long term steroid therapy and surgery?
Patients on long term steroid therapy often have adrenal atrophy so therefore are unable to mount the physiological stress response to surgery leading to hypotension
Steroid dose should be doubled (as with ‘sick day rules’). At induction, patients should be given IV steroids to prevent hypotension
What happens if warfarin and erythromycin are taken together?
Erythromycin is an enzyme inhibitor -> increased levels of warfarin -> increased INR -> increased bleeding
What are the common side effects of steroids?
STEROIDS
Stomach ulcers Thick skin Edema Right and left heart heart failure Osteoporosis Infection Diabetes Syndrome (of Cushing)
What are the common side effects of NSAIDs?
NSAID
No urine (renal failure) Systolic dysfunction (heart failure) Asthma exacerbation Indigestion (stomach ulcers) Dyscrasia (clotting abnormality)
What are the common side effects of ACE-i?
Dry cough
Hypotension
Hyperkalaemia
What are the common side effects of beta-blockers?
Wheeze in asthmatics
Bradycardia
Hypotension
Worsening of acute heart failure (but helps chronic HF)
What are the common side effects of CCBs?
Hypotension
Bradycardia
Peripheral oedema
Flushing
When should a patient be prescribed an alternative to 0.9% saline? (3 reasons)
- If they are hypernatraemic or hypoglycaemic (when 5% dextrose should be given instead)
- If they have ascites. Human albumin solution (HAS) should be given instead
- If shocked from bleeding- a crystalloid such as blood should be given instead. If none available, do not delay and administer a bolus of saline anyway.
What is the maximum rate at which IV K+ should be given?
10mmol/ hour (can be given higher by the pros)
How much fluid should be prescribed in someone who is tachycardic or hypotensive?
500ml bolus immediately (250ml if HF)
How much fluid should be prescribed in someone who is oligouric (not due to obstruction)?
1L over 2 hours and then assess
What are the general rules regarding maintenance fluids?
An adult needs 3L of fluid a day, the elderly require 2L
2 sweet, 1 salty
1mmol/kg/day of K+, Na+, Cl-
50-100g of glucose/day
Which antiemetic should be avoided in parkinsons disease?
Metoclopramide
What are the 3 first line treatments for neuropathic pain?
Amitriptyline
Pregablin
Duloxetine
3 causes for hypernatraemia?
3 Ds
Dehydration
Diabetes insipidus
Drugs- effervescent tablet preparations
Causes of microcytic anaemia?
Iron deficiency
Thalassaemia
Sideroblastic anaemia
Causes of normocytic anaemia?
Anaemia of chronic disease
Acute blood loss
Haemolytic anaemia
Renal failure (chronic)
Causes of macrocytic anaemia?
B12 folate deficiency
Excess alcohol
Liver disease
Hypothyroidism
Causes of hypokalaemia?
DIRE
Drugs (loop and thiazide diuretics)
Inadequate intake/ intestinal loss (diarrhoea/ vomiting)
Renal tubular acidosis
Endocrine (cushings, conns)
Causes of hyperkalaemia?
DREAD
Drugs (potassium sparing diuretics) Renal failure Endocrine Artefact (clotted) DKA
What are the causes for raised Alk phos?
ALK PPHOS
Any fracture Liver damage Kancer Pagets disease of bone Pregnancy Hyperparathyroidism Osteomalacia Surgery
Which projection of X-ray means that you are unable to comment of the size of the heart?
AP
How do you assess the rotation of an Xray?
If the distances between the spinous processes and clavicles are equal on both sides then there is no rotation
How do you tell if there is adequate inspiration on a chest x-ray?
If the 7th anterior rib transects the diaphragm then there is adequate inspiration
Which sign is seen in left lower lobe collapse on CXR?
Triangle behind the heart (sail sign)
What can be seen on an ECG in pericarditis?
Widespread concave ST elevation and PR depression throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6)
What actions would you take if a patient on warfarin has an INR of 5-8?
If no bleeding, omit warfarin for 2 days then reduce dose
If bleeding then omit warfarin and give 1-5mg of vitamin K
What actions would you take if a patient on warfarin has an INR of >8?
Omit warfarin and give 1-5mg of vitamin K
What is the acute management of STEMI?
A-E 300mg aspirin Morphine 5-10mg with cyclizine 50mg IV GTN Primary PCI Beta blocker
What is the acute management on NSTEMI?
A-E 300mg aspirin Morphine 5-10mg with cyclizine 50mg IV GTN Clopidogrel 300mg and LMWH/ fondaparinux Beta blocker
What is the acute management of acute left ventricular failure?
A-E Sit patient up Morphine 5-10mg with cyclizine 50mg IV GTN Furosemide 40-80mg IV (repeat) Isosorbide dinitrate infusion +CPAP
What is the acute management and likely cause of narrow irregular QRS on ECG?
Probable AF
Control rate with beta blocker or diltiazem
Consider digoxin or amiodarone if evidence of heart failure
What is the acute management and likely cause of narrow regular QRS on ECG?
SVT
Use vagal manoeuvres
Adenosine 6mg rapid IV bolus, if unsucessful give further 12mg
What is the acute management and likely cause of broad regular QRS on ECG?
Ventricular tachycardia
Amiodarone 300mg IV over 20-60 mins. Then 900mg over 24 hours
What is the acute management and likely cause of polymorphic VT on ECG?
Toursades de point
magnesium 2g over 10 mins
What is the acute management of anaphylaxis?
ABC, 15L o2
Adrenaline 500mg 1:1000 IM
once stabilised:
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
What is the acute management of an asthma attack?
100% O2 Salbutamol 5mg neb Hydrocortisone 100mg IV if severe, prednisolone 40-50mg oral if moderate Ipratropium 500mg neb Aminophylline if life threatening
What are the CURB65 criteria?
Confusion Urea >7.5mmol/L Resp rate >30/min BP systolic <90mmHg Age >65
What is the acute management of PE?
High flow o2
Morphine 5-10mg and cyclizine 50mg IV
LMWH (tinzaparin) 175 units SC daily or DOAC treatment dose
What is the acute management of bacterial meningitis?
IV fluid
4-10mg of dexamethasone
LP
2g cefotaxime IV (if immunocompromised or >55 yo add 2g ampicillin)
What is the management of status epilepticus?
Lorazepam 204mg IV or 10mg buccal midazolam
Repeat after 5 mins if no improvement
If still fitting after 5 more mins, Phenytoin 15-20mg/IV
What is the management of DKA?
IV fluid, 1L stat
Fixed rate insulin (50 units actrapid) in 50ml saline at 0.1 units/ kg/ hour
Monitor CBG and ketones hourly
10% dextrose to prevent hypoglycaemia if glucose <14mmol/L
Monitor potassium
When should you treat with antihypertensives?
If BP >150/95
Or, if >135/85 and one of the below:
Age 80 with clinic BP >150/90
Age <80 with end organ damage or CVD risk >10%
What is the target BP for people on antihypertensives?
140/90 in clinic, <135/85 ambulatory
What is the management of chronic heart failure?
ACE-i (lisinopril 2.5mg daily)
Beta-blocker (bisoprolol 1.25mg daily)
If inadequate add aldosterone receptor antagonist (spironolactone 25mg daily)
What do different chadsvasc scores suggest for treatment?
Score of 0= no anticoagulation
Score of 1= consider DOAC in men using a vitamin K antagonist
Score of 2+= consider anticoagulation in men and women
What is the management of hypertension?
If <55 and not of Afro-Caribbean origin: ACE-i or ARB, add CCB or thiazide diuretic if not enough or both if that is unsucessful
If >55 or afro-caribbean origin: CCB, add ACE-i or ARB or thiazide like diuretic if not enough
What do the different HASBLED scores correlate to?
Score of 0= low risk of bleeding, anticoagulation should be strongly considered
Score of 1-2= low to moderate risk of bleeding, anticogulation should be considered
Score>/=3= high risk of major bleeding, alternatives to anticoag should be considered
What is the management of new onset AF <48hrs?
Rhythm control by cardioversion. Can be electrical or pharmacological (flecanide if no structural heart disease, amiodarone if structural heart disease)
What is the management of AF which started >48hrs ago?
Rate control. Use either a beta blocker (bisoprolol 2.5mg OD) or a rate limiting CCB (diltiazem 120mg daily). If this is not effective then commence dual therapy with a beta blocker or CCB and digoxin
What are the contraindications for beta-blockers?
hypotension, asthma, acute heart failure
What are the contraindications for calcium channel blockers?
Hypotension, bradycardia and peripheral oedema
What is the management of stable angina?
- GTN spray
- Secondary prevention- aspirin, statin and CVD risk factor modification
- Beta-blocker or CCB
What is the management of chronic asthma?
- SABA and low dose ICS
- add inhaled LABA (this can be part of a MART)
- Increase dose of ICS or add LTRA. If there is no response to LABA at this point then stop
- Refer on
Which blood glucose therapy can be started when metformin is contraindicated or not-tolerated?
DPP4-i
Pioglitaone
SU
What is the most commonly used regimen in parkinsons disease?
co-beneldopa or co-careldopa
What is the first line drug (for males and for females) in myoclonic seizures?
Males= valporate Females= levetiracetam
What is the first line drug (for males and for females) in tonic seizures?
Males= valporate Females= lamotrigine
What is the first line drug (for males and for females) in focal seizures?
Males= carbamazipine Females= lamotrigine
What are the 3 AChE inhibitors which can be used in alzheimers disease?
Donepezil, rivastigmine and galantamine
What is the management of an acute flare of crohn’s disease?
prednisolone 20-40mg orally. If severe, IV hydrocortisone
Which drugs can be used to induce remission in crohn’s disease?
Azathioprine. It is metabolised by the enzyme thiopurine S-methyl transferase (TPMT) which 10% of the population have a congenitally low activity with. It is important to check TPMT levels before starting, if levels are low then start methotrexate
What are the notable side effects of lamotrigine?
Rash, rarely steven-johnson syndrome
What are the notable side effects of carbamazipine?
Rash, dysarthria, ataxia, nystagmus and hyponatraemia
Name 2 examples of a stool softener
Docusate sodium
Arachis oil
What is a contraindication to arachis oil?
Nut allergy
Name a bulking agent
Isphagula husk
Name 2 stimulant laxatives
Senna
Bisacodyl
Name 2 osmotic laxatives
Lactulose
Phosphate enema
What is a contraindication to isphagula husk?
Faecal impaction
Colonic atony- reduced gut motility
What is a contraindication to bisacodyl
Acute abdomen
What is a contraindication to a phophate enema?
Acute abdomen, IBD
What are the notable side effects of phenytoin?
Ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity
What are the notable side effects of sodium valporate?
Tremor, teratogenicity, weight gain
What are the notable side effects of levetiracetam?
Fatigue, mood disorders and agitation
What is the management on non-infective diarrhoea?
Loperamide 2mg oral up to 3hrly
Codeine 30mg oral up to 6hrly
What should be given for CVD risk factor management in diabetes (1 and 2)?
Aspirin 75mg daily if any significant CV risk factors (or >50 DMT2)
Atorvastatin 20mg daily if significant CV risk factors (or >40 DMT2)
What is the reversal agent for benzodiazepine overdose?
Flumazenil
What is the management of hyperkalaemia?
10mls of 10% calcium gluconate to stabilise the myocardium
Actrapid insulin (10 units) and 50mls of 50% dextrose
Which condition can a combination of CCB and steroids worsen?
Biventricular heart failure
When should metformin use be avoided?
In those with a creatinine >150 because it causes lactic acidosis. Should also be avoided/stopped in those with a eGFR <30
Which antiemetic should be used in the event of ileus and gastric stasis?
Metoclopramide / domperidone
Which antiemetic should be used in the event of nausea induced by chemotherapy?
Ondansetron
Which antiemetic should be used in the events of obstruction, vestibular causes, peritoneal irritation and raised intracranial pressure?
Cyclizine
How long does an oral/SC/IV opioid need to be continued for when transferring over to a fentanyl patch?
Should be continued for 12 hours after application of the patch to allow the plasma level to reach a therapeutic level
