Practical Prescribing

Question 1

In which patients in need of fluid replacement do you give dextrose 5% rather than 0.9% saline?

Answer 1

Hypernatremic

Hypoglycaemic

Question 2

How much and how fast do you give in a fluid challenge? What about in heart failure?

Answer 2

500ml stat (<15mins)

Heart failure 250ml stat

Question 3

How do you roughly work out how fluid deplete a patient is?

Answer 3

1) reduce urine output (<30ml/ hour) indicates 500ml deplete
2) reduce U.O plus tachycardia indicates 1L deplete
3) reduce U.O, tachycardia and shocked indicates >2L deplete

Question 4

Prescribe anti emetics cyclizine and metoclopramide. Indicate when each may be contraindicated?

Answer 4

Cyclizine 50mg / 8hourly oral/IM/IV (CI in heart failure/ problems as causes fluid retention)

Metoclopramide 10mg/ 8 hourly IM/IV (CI in parkinsons as D2 agonist, also young women as causes dyskinesia)

Question 5

In AF, when should diltazam (CCB) be avoided?

Answer 5

In odeama as CCB worse fluid retention

Question 6

Which group of people is adenosine contraindicated in?

Answer 6

Asthmatics

Use verapamil instead

Question 7

In acute asthma (adults) what do you give and how much?

Answer 7

O2
Salbutamol nebs 5mg every 20-30mins
Steriods - pred oral 40-50mg od OR hydrocortisone 100mg IV QDS

Then ipatropium bromide

Question 8

What level should INR be prior to elective surgery (in someone who will have stopped warfarin 5 days prior) and was is the management if not?

Answer 8

<1.5

If higher give phytomenadione 5mg oral (vit K)

Question 9

POP and enzyme inducing drugs?

Answer 9

Reduced effectiveness - there change to a alternative contraception until 4 weeks after other medication finished.

Question 10

How quickly do you give a fluid challenge?

Answer 10

500/15 mins

1000/30 mins

Question 11

What insulin do you stop/continue/add in someone with a DKA?

Answer 11

Stop short acting, continue long acting and add a fixed rate insulin alongside fluid resuscitation

Question 12

Which opiates should be used in renal impairment?

Answer 12

Oxycodone as it is metabolised by the liver and will not build up in renal disease.

Question 13

Patient on amiodarone get thyroid dysfunction, what should be done in regards to the amiodarone?

Answer 13

Stop it

Question 14

Drugs to stop/change prior to surgery?

Answer 14

Anti-coagulation And contraception - stop

Diabetic meds - switch

Question 15

What are the main rules for fluid balance?

Answer 15

Input = output

If output in 250ml per hour, 1L in 4 hours this needs replacing at the same rate.

Look at electrolytes, don’t give k+ more than 10mmol/20mmol per hour.

Question 16

Treatment in hyperkalemia?

Answer 16

10ml 10% IV calcium gluconate, 10units of actrapid insulin with 100ml 20% IV dextrose and nebulised salbutamol.

Question 17

Causes of hyperkalemia

Answer 17

DREAD
Drugs
Renal failure
Endocrine
Artefact 
Diabetic ketoacidosis

Question 18

First line management in anaphylactic reactions?

Answer 18

1) stop drug/ source
2) ABCDE
3) adrenaline, chlorphenamine

Question 19

In a COPD exacerbation what comes after salbutamol nebs?

Answer 19

Ipratropium bromide 500 micrograms neb

Question 20

What’s the relationship between statins and clarithromycin?

Answer 20

Clarithromycin is a cyp3a4 inhibitor, if taken stop statin as will increase risks of toxicity or side effects.

Don’t eat grapefruits either

Question 21

Treatment for UC flare? Serve vs mild?

Answer 21

Mild oral steroids eg prednisolone 30mg OD

Severe IV hydrocortisone (100mg) 6-hourly