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Prescribing Flashcards

1
Q

Name some Enzyme Inducing drugs

What is the effect of this?

A

PC BRAS

Phenytoin
Carbemazapine
Barbituates
Rifampicin
Alcohol (Chronic Excess)
Sulphonylureas

These drugs increase enzyme activity and so decrease drug concentration

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2
Q

Name some Enzyme Inhibiting drugs

What is the effect of this?

A

AO DEVICES

Allopurinol
Omeprazole
Disulfiram
Erythromycin
Valproate
Isoniazid
Ciprofloxacin
Ethanol (acute intoxication)
Sulphonamides

These drugs DECREASE enzyme activity so INCREASE drug concentration

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3
Q

Outline VTE Prophylaxis options

A

Pharmacological: LMWH/ Anticoagulant
Mechanical: TED stockings/ IPS

LMWH = most effective –> all patients with decreased mobility should be given a LMWH.
Contraindications: Active bleeding, stroke –> Mechanical - TED/IPC instead

Patients already on anticoag = continue pre-prescribed medication, no enoxaparin.

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4
Q

Name common drugs which should be STOPPED before surgery

A

I LACK OP

Insulin,
Lithium, (day before surgery)
Anticoagulants/antiplatelets, (variable - occasionally continued)
COCP/HRT, (4 weeks before surgery)
K -sparing diuretics,
Oral hypoglycaemics,
Perindopril + other ACE-inhibitors.

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5
Q

What is the mnemonic to remember a Safe Prescribing routine?

A

PReSCRIBER

Patient Details
Reaction - Allergies
Sign the front of the chart
Contraindications - check for contraindications to each drug
Route
IV fluids - prescribe if needed
Blood clot - prescribe VTE prophylaxis if needed
Emetic - Prescribe Anti-emetic if needed
Relief - Prescribe pain relief if needed

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6
Q

What is important to remember when checking patient details?

A

If working with a new chart then you must write three pieces of patient-identifying information on the front of the chart (e.g. patient name, date of birth and hospital number) or use a hospital addressograph sticker.

• If amending a chart then ensure that you have the correct patient’s drug chart.

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7
Q

What is important to remember about checking for allergic reactions?

A

If working with a new chart then complete the allergy box including any drug reaction mentioned by the patient.

• If amending a chart then check the allergy box before prescribing.

REMEMBER: Tazocin and Co-amoxiclav contain penicillin

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8
Q

Which 4 groups of drugs must you know the contraindications for?

A

Antiplatelets/Anti-coagulants
Steroids
Antihypertensives
NSAIDs

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9
Q

What are the contraindications to drugs that increase bleeding? (E.g. anti-platelets and anti-coagulants)

A
  • Active bleeding, suspected bleeding or at risk of bleeding (e.g. Prolonged Prothrombin time due to liver disease)

-

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10
Q

Name an enzyme inhibitor and explain how this might interact with Warfarin?

A

Erythromycin

Can increase Warfarin’s effect (and therefore increase PT and INR) despite a stable dose.

Should be considered in patient’s presenting with excessive anticoagulation

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11
Q

What are the side effects of Steroids?

A

STEROIDS mnemonic

Stomach Ulcers
Thin skin
Edema
Right & Left Heart Failure
Osteoporosis
Infection (including Candida)
Diabetes (commonly causes hyperglycaemia)
Syndrome - Cushing’s syndrome

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12
Q

What are the safety considerations which should be remembered when prescribing NSAIDs?

A

NSAIDs mnemonic

No urine (i.e. renal failure)
Systolic dysfunction (i.e. heart failure)
Asthma
Indigestion (any cause)
Dyscrasia (clotting abnormality)

(Aspirin is technically an NSAID but is used at relatively low doses for management of CV & cerebrovascular disease - not subject to same level of caution as NSAIDs used for pain management)

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13
Q

What are some side effects of all antihypertensives?

A

Hypotension, including postural hypotension

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14
Q

Which antihypertensives might cause bradycardia?

A

Beta blockers and some CCBs

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15
Q

Which antihypertensives can cause electrolyte disturbance?

A

ACEi and diuretics

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16
Q

Which antihypertensives can cause a dry cough?

A

ACEi

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17
Q

which anti-hypertensives can cause peripheral oedema and flushing?

A

CCBs

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18
Q

Which anti-hypertensives can cause wheeze in asthmatics and worsening of acute heart failure?

A

Beta-blockers

They cause worsening of acute heart failure, but help in chronic heart failure

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19
Q

What side effects can diuretics cause?

A

Diuretics can cause renal failure

Thiazide diuretics can cause gout

potassium sparing diuretics can cause gynaecomastia

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20
Q

What 2 situations are fluids prescribed in?

A

REPLACEMENT: for dehydration/acutely unwell patient

MAINTENANCE: In a patient who is nil by mouth

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21
Q

Give all patients 0.9% saline (normal saline, a crystalloid) unless…

A
  • Hypernatraemic or hypoglycaemic
  • Ascites
  • Is shocked from bleeding
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22
Q

What should you give a patient who is hypernatraemic or hypoglycemic?

A

5% dextrose

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23
Q

what fluids should you give a patient with ascites?

A

HAS - albumin maintains oncotic pressure - plus higher sodium content in 0.9% saline will worsen ascites

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24
Q

What should you give a patient in shock from bleeding?

A

Blood transfusion, crystalloid if no blood is available.

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25
Q

How do we decide how much fluid to give and how fast?

A

Assess HR, BP and UO

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26
Q

How much fluid should we give if a patient is tachycardic or hypotensive?

A

500 mL bolus immediately (250 mL if history of heart failure) then reassess patient.

repeat up to 2L

27
Q

How much fluid should we give to a patient who is only oliguric?

A

Give 1L over 2-4 hours, reassess.

28
Q

what is the maximum speed at which IV potassium should be given?

A

no more than 10mmol/hour

29
Q

How much fluid do adults require daily?

A

3L per 24hours, 2L for elderly

Adequate electrolyes are provided by L of 0.9% saline and 2L of 5% dextrose
(1 salty and 2 sweet)

30
Q

Before prescribing fluids, what should you assess in every patient?

A
  • Check U&Es to confirm what to give them
  • Check patient is not fluid overloaded (e.g. increased JVP or peripheral and pulmonary oedema)
  • Ensure bladder is not palpable (signifying urinary obstruction) if giving replacement fluids because of reduced urine output
31
Q

When should metoclopramide be avoided? (dopamine antagonist)

A
  • Patients with Parkinson’s disease -> Exacerbate symptoms
  • Young women -> Risk of dyskinesia i.e. unwanted movements especially acute dystonia
32
Q

What options do we have for anti-emetics for the nauseated patient?

A

CYCLIZINE 50mg 8hrly IM/IV.ORal for most cases. (Good first line for all patients except cardiac cases as it can cause fluid retention)

METOCLOPRAMIDE 10mg 8hrly IM/IV if Heart Failure

ONDANSETRON 4mg or 8mg 8hrly IV/Oral

33
Q

What pain relief is first line for neuropathic pain?

A

Amitriptyline 10mg PO nightly

or

Pregabalin 75mg 12 hourly

34
Q

What pain relief is best for painful diabetic neuropathy?

A

DULOXETINE 60mg PO daily

35
Q

What is important to remember when prescribing paracetamol?

A

Remember to check how much paracetamol a patient is taking, especially if they are on more than one preparation. e.g. paractamol plus cocodamol.

MUST ensure that no more than 4g of paracetamol is given per day.

In patients <50kg the MAX dose of paracetamol is 500mg 6hrly

36
Q

Analgesic choice table for no pain, mild pain, severe pain

37
Q

What is a common presentation for anti-muscarinic toxicity? Name some common anti-muscarinic drugs

A

Pupil dilation with loss of accommodation,

dry mouth,

tachycardia

Confusion in the elderly ( Lower dose in elderly)

Antimuscarinics: Oxybutynin, Solifenacin, Tolterodine, Ipratroprium

38
Q

Name 3 causes of microcytic anaemia (low MCV)

A

Iron deficiency anaemia

Thalassaemia

Sideroblastic anaemia

39
Q

Name the causes of a normocytic (normal MVC) anaemia

A

Anaemia of chronic disease

Acute blood loss

Haemolytic anaemia

renal failure (chronic)

40
Q

Name some causes of a macrocytic anaemia (High MCV)

A
  • B12/folate deficiency (MEGALOBLASTIC anaemia)
  • Excess alcohol
  • Liver disease (incl. non-alcoholic causes)
  • Hypothyroidism
  • Haematological diseases beginning with M: Myeloproliferative, myelodysplastic, multiple myeloma
41
Q

Name some causes of high neurophils (NEUTROPHILIA)

A

- Bacterial Infection

  • Tissue damage (inflammation, infarct, malignancy)
  • Steroids
42
Q

Name some causes of low neutrophils

A
  • Viral infection
  • Chemotherapy//Radiotherapy
  • CLOZAPINE (Antipsychotic)
  • CARBIMAZOLE (antithyroid)
43
Q

Name some causes for high lymphocytes (lymphocytosis)

A
  • Viral infection
  • lymphoma
  • chronic lymphocytic leukaemia
44
Q

Name some causes for Low platelets (THROMBOCYTOPENIA)

A

Due to REDUCED PRODUCTION:

  • Infection (usually viral)
  • drugs
  • myelodysplasia, myeloma

or INCREASED DESTRUCTION:

  • HEPARIN
  • hypersplenism
  • DIC
  • ITP
  • TTP
45
Q

Name some causes of high platelets (THROMBOCYTOSIS)

A

Reactive

  • Bleeding
  • Tissue damage (infection, inflammation, malignancy)
  • post splenectomy

Primary: myeloproliferative disorders

46
Q

What are the two principle abnormalities to look for in U&Es?

A
  • High/Low electrolytes
  • Presence and type of kidney injury
47
Q

Name some causes of HYPOVOLAEMIA + HYPONATRAEMIA

A
  • Fluid loss (D/V)
  • Addisons disease
  • DIURETICS

DIURETICS CAUSE HYPONATRAEMIA IN THE PRESENCE OF HYPOVOLAEMIA

48
Q

Name some causes of HYPONATRAEMIA with HYPERVOLAEMIA

A
  • Heart failure
  • Renal Failure
  • liver failure
49
Q

Name some causes of HYPERNATRAEMIA

(all begin with D)

A
  • DEHYDRATION
  • DRIPS (i.e. too much IV saline)
  • DRUGES (effervescent tablets or IV preps with high sodium content)
  • DIABETES INSIPIDUS
50
Q

Causes of SIADH

A

mnemonic SIADH

  • Small Cell lung carcinoma
  • Infection
  • Abscess
  • Drugs: CARBEMAZEPINE & ANTIPSYCHOTICS
  • Head Injury
51
Q

Why are hypokalaemia and hyperkalaemia particularly important?

A

They can cause fatal cardiac arrythmias!

52
Q

Causes of hypokalaemia?

Causes of hyperkalaemia?

DIRE & DREAD

A

Causes of HypOkalaemia: (DIRE)

Drugs: Loop & Thiazide diuretics

Inadequate intake or intestinal loss (D/V)

Renal Tubular Acidosis

Endocrine (Cushing’s and Conn’s syndromes)

Causes of HypERkalaemia: (DREAD)

Drugs: Potassium-sparing diuretics &ACEi

Renal Failure

Endocrine (Addison’s Disease)

Artefact (very common, due to clotted sample_

DKA (When insulin is given to treat DKA, potassium drops so regular (hourly) monitoring required +/- replacement)

53
Q

What does a raised urea indicate?

A

Kidney injury or Upper GI bleed

Raised urea, normal creatinine in non-dehydrated patient → look at Hb → if low = Upper GI bleed is probable.

54
Q

What are the 3 different types of AKI?

A

Prerenal (70%)

Intrinsic renal (10%)

Postrenal (20%) (obstructive)

55
Q

What biochemical disturbance would be seen in a prerenal AKI?

Name some causes of prerenal AKI

A
  • UREA RISE >> CREATININE RISE
  • Causes: Dehydration, shock, sepsis, blood loss, renal artery stenosis (ACEi or NSAIDs cause hypoperfusion of kidneys)
56
Q

What biochemical disturbance would be seen in intrinsic renal AKI?

Name some causes of intrinsic renal AKI

A

CREATININE RISE >> UREA RISE, bladder not palpable

Causes: INTRINSIC mnemonic

  • Ischaemia (due to prerenal AKI, causing acute tubular necrosis)
  • Nephrotoxic antibiotics (Gentamicin, vancomicin, tetracyclines)
  • Tablets (ACEi, NSAIDs)
  • Injury (Rhabdomyolysis)
  • Negatively bifringent crystals (gout)
  • Syndromes (glomerulonephridites
  • Inflammation (Vasculitis)
  • Cholesterol Emboli
57
Q

What biochemical disturbance would be seen in postrenal (obstructive) AKI?

Name some causes of postrenal AKI

A

CREATININE RISE >> UREA RISE, bladder palpable

Causes:

  • In lumen: stone
  • In wall: tumour (renal cell, transitional cell), fibrosis
  • External pressure: BPH, prostate cancer, lymphadenopathy
58
Q

What might an isolated raised bilirubin be a sign of?

A

Pre-hepatic jaundice

Bilirubin = breakdown product of Hb → solitary raised Hb usually indicates haemolysis

59
Q

What are the causes of a raised ALP?

Alk Phos

A

Common cause mnemonic- ALKPHOS

  • Any fracture
  • Liver damage (post hepatic)
  • K = cancer
  • Paget’s disease of bone + Pregnancy
  • Hyperparathyroidism
  • Osteomalacia
  • Surgery
60
Q

What pattern of LFT derangement would be seen in prehepatic jaundice

61
Q

What pattern of LFT derangement would be seen in Intrahepatic jaundice?

62
Q

What pattern of LFT derangement may be seen in Post-hepatic jaundice (obstructive)

A

Drugs: FLUCLOXACILLIN, CO-AMOXICLAV, NITROFURANTOIN, STEROIDS and SULPHONYLUREAS

63
Q

How should we approach adjusting levothryoxine dose?

A

Use TSH as a guide

Target range 05-5mlU/L and unless grossly hypo/hyperthyroid, change by smallest incremene offered.

Finals (8 decks)

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