Planning Management

Question 1

First line antiemetic control in pregnancy?

Answer 1

Cyclizine is the first line antiemetic control in pregnancy unless contraindicated.

Other first line drugs are promethazine, chlorpormazine and prochlorperazine.

Question 2

How is DKA managed according to BNF?

Answer 2

BNF recommendation for management of DKA:

• IV fluids: 500ml of 0.9% sodium chloride if systolic BP is below 90 and repeat if SBP remains below 90. When BP is over 90, 0.9% sodium chlride can be given at a rate that replaces the deficit and provids maintenance.
• Potassium chloride: Add to 0.9% sodium chloride unless anuria is suspected and adjust according to serum potassium concentration.
• Fixed rate IV insulin infusion: Soluble insulin (Actrapid or Humulin S) is diluted and mixed with 0.9% sodium chloride and infused at a fixed rate of 0.1 units/kg/hour. This can be stopped when the blood ketone concentration is <0.3mmol/l, the blood pH is above 7.3 and the patient can eat and drink.
• Long acting insulin: should be continued during treatment of DKA.
• Monitor blood ketone and blood glucose concetrations hourly and adjust the insulin infusion rate accordingly. Once blood glucose falls below 14mmol/l, IV glucose 10% can be given with 0.9% sodium chloride.

Question 3

Pharmacological management for AECOPD?

Answer 3

Oxygen: initially give oxygen via a Venturi 24% or 28% mask, aiming for an oxygen saturation of 88-92%.

Oral Steroids: Prednislone 30mg once daily for seven days with appropriate reducing dose if indicated.

Antibiotics: Should be considered if signs of infection (purulent sputum raised inflammatory markers).

Short-acting bronchodilators

Question 4

Example of osmotic laxative?

Answer 4

Lactulose is an osmotic laxative. It draws water from the body into the bowel to soften the stool and make it easier to pass.

Question 5

Example of bulk forming laxative?

Answer 5

Ispaghula husk. This contains soluble fibre and retains fluid with stool, stimulating peristalsis.

Question 6

Management for trigeminal neuralgia?

Answer 6

Treatment of trigeminal neuralgia is usually with anticonvulsants such as Carbamazepine. Lamotrigine, phenytoin or gabapentin may also be used on an individual basis if carbamazepine is ineffective or not tolerated.

Question 7

Which strong opioid is used in renal impairment?

Answer 7

Morphine is the first line strong opioid in patients with normal renal function. However, since morphine is metabolised in the kidneys, patients with renal impairment should receive oxycodone or fentanyl.

Question 8

Which strong opioid is used in renal impairment?

Answer 8

Oxycodone or fentanyl

Morphine is the first line strong opioid in patients with normal renal function. However, since morphine is metabolised in the kidneys, patients with renal impairment should receive oxycodone or fentanyl.

Question 9

What is the most appropriate form of contraception for a patient with past breast cancer?

Answer 9

Copper IUD

All hormonal contraceptives are contraindicated (COCP, IUS, POP, Implant) in patients with current or past breast cancer. This is because the increased exposure to oestrogen is a risk factor for breast cancer.

The copper coil is contraindicated in patients with endometrial cancer.

Question 10

Drug for prevention of sickle cell crises?

Answer 10

Hydroxycarbamide

Question 11

Example of stimulant laxative?

Answer 11

Senna. It works by stimulating colonic nerves resulting in peristalsis and increasing intestinal motility. Other stimulant laxatives include bisacodyl and sodium picosulfate.

Question 12

How long is anticoagulation given for in provoked and unprovoked PE?

Answer 12

Anticoagulation should be continue for at least 3 months in patients with a provoked PE and consideration should be taken to extend treatment beyond 3 months in patients with an unprovoked PE

Question 13

Briefly mention treatment for hyperkalaemic patients?

Answer 13

Renal patients are prone to hyperkalaemia which is an emergency due to high levels causing arrythmias and cardiac arrest.

Often patients may be dehydrated so IV rehydration can decrease the potassium level.

• IV calcium gluconate
• IV insulin with dextrose
• Salbutamol nebulisers

Question 14

Antihypertensive of choice for diabetics?

Answer 14

ACEi are the drug of choice if the person is diabetic as they are renoprotective.

Question 15

Antihypertensive of choice for patients aged over 55 years?

Answer 15

Calcium channel blocker

Question 16

First line treatment for cellulitis?

Answer 16

Flucloxacillin, very effective against staph aureus.

Question 17

Drug treatment for UGIB from oesophageal varices?

Answer 17

IV Terlipressin

Question 18

Folic acid dose for women who are at an increased risk of having a pregnancy affected by a neural tube defect?

High risk:

• Mother or father having a NTD
• Previous prenancy with NTD
• FH of NTD
• Diabetes
• Taking antiepileptic medication

Answer 18

High risk patients are advised to take 5mg of folic acid daily until week 12 of pregnancy

Question 19

Drug used for hypertension in phaeochromocytoma?

Answer 19

Phenoxybenzamine

Question 20

What should be checked before starting COCP?

Answer 20

Two most relevant further actions before deciding on whether to prescribe a combined oral contraceptive pill are smoking status and blood pressure.

Blood pressure should be checked before starting the combined oral contraceptive pill (COCP) and at least annually. Not only does hypertension increase the risk of cardiovascular events but a small number of women using the COCP develop high blood pressure as a side-effect.

Her smoking status is important as being older than 35 years and smoking more than 15 cigs/day is an absolute contraindication to the COCP.

Question 21

Drug treatment for vulvovaginal candidiasis in pregnant woman?

Answer 21

Clotrimazole pessary 100mg PV daily for 7 days.

Prolonged treatment is advised for candidal infection in pregnancy. Systemic therapy is not recommended during pregnancy.

Question 22

Drug for repeated C.diff infection?

Answer 22

Oral Vancomycin is used for repeated c.diff infection where usual first line therapy with oral metronidazole has failed or is not tolerated.

Question 23

Briefly, management for DKA? What about patient’s insulin prescription?

Answer 23

Patient requires fixed rate IV insulin 0.1 units/kg/hour alongside fluid resuscitation with 0.9% sodium chloride.

Short acting SC insulin should be stopped and long acting insulin (determir or glargine) should be continued during treatment of DKA.

Question 24

How many days before surgery should Warfarin be stopped? and what is the cut off point?

Answer 24

Warfarin sodium should usually 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.