Prescribing Safety Assessment

Question 1

What makes a safe and legal prescription? Must be what?

Answer 1

Date, identification of the patient, name of the drug, formulation, dose, frequency of administration, route of administration, amount to be supplied (GP only,) prescribers signature, must be legible
Legible, unambiguous, an approved name, in capitals, without abbreviations, signed, if ‘as required’: 2 instructions- 1) indication, 2) maximum frequency, if antibiotic= include the indication and stop/ review date

Question 2

Don’t get marks for doing what if the prescription written is wrong?

Answer 2

Signing name and date

Question 3

What does an enzyme inducer do? What does an enzyme inhibitor do?

Answer 3

They increase P450 enzyme activity, hastening the metabolism of other drugs with the result that they exert a reduced effect- thus a patient will require more of some other drugs in the presence of an enzyme inducer

Decrease P450 enzyme activity–> increased levels of other drugs e.g. warfarin can cause a dangerous rise in INR

Question 4

What are the most common enzyme inducers? Inhibitors? What happens if atorvastatin is given with macrolides?

Answer 4

PC BRAS: phenytoin/ pioglitazone, carbamazepine, barbiturates, rifampicin, alcohol, sulfonylureas, cigarette smoke, solvents, some antimicrobials

AODEVICES: allopurinol/ amiodarone, omeprazole, disulfiram, erythromycin, valproate, isoniazid, ciprofloxacin, ethanol, sulphonamides/ SSRIs
Grapefruit juice, cimetidine- think CEMENT, macrolides e.g. erythromycin/ clarithromycin
Increase muscle pain, tenderness and/or dark coloured urine

Question 5

Patients on long-term corticosteroids e.g. prednisolone should be given what at induction of anaesthesia?

Answer 5

IV steroids to prevent profound hypotension

Question 6

Drugs to stop before surgery?

Answer 6

I LACK OP: insulin- metformin(will cause lactic acidosis,) lithium, anticoagulants/ antiplatelets, COCP/ HRT, K+- sparing diuretics, oral hypoglycaemics- would cause hypoglycaemia(sliding scale should be started instead,) perindopril and other ACE-i

Question 7

When to stop COCP + HRT before surgery? Lithium? K+-sparing diuretics and ACE-i? Anticoagulants and antiplatelets? Oral hypoglycaemic drugs and insulin?

Answer 7

4 weeks
Day before
Day of surgery
Variable
Variable

Question 8

Mnemonic for prescribing essentials?

Answer 8

PReSCRIBER: patient details= name, DOB and hospital number, reaction i.e. allergy plus the reaction, sign the front of the chart, check for CI to each drug, route, IV fluids if needed, blood clot prophylaxis if needed, antiEmetic if needed and pain Relief if needed

Question 9

What are never events?

Answer 9

Serious and avoidable medical errors for which there should be preventative measures in place to stop their occurrence

Question 10

What are biological medicines?

Answer 10

Those made by or derived from a biological source using biotechnology processes such as recombinant DNA technology- size, complexity and how they’re produced may result in a degree of natural variability in molecules of the same active substance particularly in different batches of the medicine e.g. insulin, MABs

Question 11

What is a biosimilar medicine? How should they be prescribed? Adverse reaction reports should clearly state what? Report using what?

Answer 11

A biological medicine that is highly similar and clinically equivalent to an existing biological medicine that has already been authorised in the EU- active substance is similar but not identical to the originator biological medicine
Choice to prescribe lies with the clinician in consultation with the patient- must be prescribed by brand name and the brand name specified should be dispensed
Brand name and batch number
To the MHRA through the Yellow Card Scheme

Question 12

Drugs available as biosimilar drugs?

Answer 12

Adalimumab
Bevacizumab
Enoxaparin sodium
Epoetin alfa
Epoetin zeta
Etanercept
Filgrastim
Follitropin alfa
Infliximab
Insulin glargine
Insulin lispro
Rituximab
Somatropin
Teriparatide
Trastuzumab

Question 13

When are oral syringes supplied? How should they be labelled?

Answer 13

When oral liquid medicines are prescribed in doses other than multiples of 5ml
The oral syringe is marked in 0.5 mL divisions from 1 to 5 mL to measure doses of less than 5 mL (other sizes of oral syringe may also be available). It is provided with an adaptor and an instruction leaflet. The 5–mL spoon is used for doses of 5 mL (or multiples thereof)
Oral/ enteral in a large font size- practitioner’s responsibility

Question 14

What might the presence of propylene glycol interact with? High content of sodium considered as what?

Answer 14

Disulfiram and metronidazole
Containing ≥ 17 mmol sodium= 20% WHO recommended max daily dietary intake for an adult

Question 15

How to prevent adverse reactions?

Answer 15

Never use any drug unless there is a good indication. If the patient is pregnant do not use a drug unless the need for it is imperative;
Allergy and idiosyncrasy are important causes of adverse drug reactions. Ask if the patient had previous reactions to the drug or formulation;
Ask if the patient is already taking other drugs including self-medication drugs, health supplements, complementary and alternative therapies; interactions may occur;
Age and hepatic or renal disease may alter the metabolism or excretion of drugs, so that much smaller doses may be needed. Genetic factors may also be responsible for variations in metabolism, and therefore for the adverse effect of the drug; notably of isoniazid and the tricyclic antidepressants;
prescribe as few drugs as possible and give very clear instructions to the elderly or any patient likely to misunderstand complicated instructions;
Whenever possible use a familiar drug; with a new drug, be particularly alert for adverse reactions or unexpected events;
consider if excipients (e.g. colouring agents) may be contributing to the adverse reaction. If the reaction is minor, a trial of an alternative formulation of the same drug may be considered before abandoning the drug;
Warn the patient if serious adverse reactions are liable to occur.

Question 16

When is a drug reaction likely to be caused by drug allergy?

Answer 16

The reaction occurred while the patient was being treated with the drug, or
The drug is known to cause this pattern of reaction, or
The patient has had a similar reaction to the same drug or drug-class previously

Question 17

Drugs capable of causing oral ulceration?

Answer 17

Cytotoxic drugs, e.g. methotrexate. Other drugs capable of causing oral ulceration include ACE inhibitors, gold, nicorandil, NSAIDs, pancreatin, penicillamine, proguanil hydrochloride, and protease inhibitors

Question 18

Lichenoid eruptions associated with what drugs? Candidiasis can complicate treatment with what?

Answer 18

ACE inhibitors, NSAIDs, methyldopa, chloroquine, oral antidiabetics, thiazide diuretics, and gold
Antibacterials and immunosuppressants- occasional for corticosteroid inhalers

Question 19

Chlorhexidine mouthwash can cause what? Iron salts in liquid form can do what? Intrinsic staining of the teeth most commonly caused by what? CI in who?

Answer 19

Brown staining of the teeth- can be removed by polishing
Stain the enamel black
Tetracyclines during pregnancy, in breast-feeding women, in children under 12 years

Question 20

Excessive ingestion of fluoride leads to what?

Answer 20

Dental fluorosis with mottling of the enamel and areas of hypoplasia or pitting, mild mottling if dose is too large for child’s age

Question 21

Who is at risk of osteonecrosis of the jaw?

Answer 21

Those receiving bevacizumab or sunitinib for cancer, IV bisphosphonates> those receiving oral for osteoporosis or Paget’s disease

Question 22

Gingival overgrowth is a SE of what? Most common effect on the salivary glands? Those at greater risk of dental caries and oral infections particularly candidiasis?

Answer 22

Phenytoin and sometimes of ciclosporin or of nifedipine
To reduce flow(xerostomia)
Those with poor oral hygiene / persistently dry mouth

Question 23

Drugs implicated in xerostomia?

Answer 23

Antimuscarinics, antidepressants, alpha-blockers, antihistamines, antipsychotics, baclofen, bupropion hydrochloride, clonidine hydrochloride, 5HT1 agonists, opioids, tizanidine, diuretics

Question 24

Drugs that can increase saliva production? Pain in salivary glands? Swelling?

Answer 24

Clozapine, neostigmine
Some antihypertensives e.g. clonidine hydrochloride, methyldopa. vinca alkaloids
Iodidies, antithyroid drugs, phenothiazines and sulfonamides

Question 25

Drugs implicated in decreased taste acuity or alteration in taste sensation?

Answer 25

Amiodarone hydrochloride, calcitonin, ACE inhibitors, carbimazole, clarithromycin, gold, griseofulvin, lithium salts, metformin hydrochloride, metronidazole, penicillamine, phenindione, propafenone hydrochloride, protease inhibitors, terbinafine, and zopiclone

Question 26

When is the neonatal period? Child? What should be avoided in children? Doses of drugs based on what? Many are standardised by what?

Answer 26

First 28 days of life, 1 month- 17 years IM injections Age ranges, body-weight in kg Weight, sometimes body surface area in metres 2

Question 27

What drugs are excreted in the bile unchanged and can accumulate in patients with intrahepatic or extrahepatic obstructive jaundice?

Answer 27

Fusidic acid, rifampicin

Question 28

Reduced hepatic synthesis of blood-clotting factors indicated by a prolonged prothrombin time increases sensitivity to what? What drugs can further impair cerebral function and precipitate hepatic encephalopathy? Oedema and ascites in CLD exacerbated by what?

Answer 28

Oral anticoagulants such as warfarin sodium and phenindione Sedative drugs, opioid analgesics, diuretics producing hypokalaemia, drugs causing constipation NSAIDs and corticosteroids (give rise to fluid retention)

Question 29

Why do issues arise in patients with reduced renal function? How to avoid these?

Answer 29

Reduced renal excretion of a drug or its metabolites may cause toxicity; sensitivity to some drugs is increased even if elimination is unimpaired; many side-effects are tolerated poorly by patients with renal impairment; some drugs are not effective when renal function is reduced. By reducing the dose or by using alternative drugs

Question 30

The effects of renal impairment on drug elimination usually stated in terms of what? Exceptions to the use of eGFR where Cr Cl is recommended include what?

Answer 30

Creatinine clearance Toxic drugs, in elderly patients and in patients at extremes of muscle mass

Question 31

Formula for using creatinine clearance? When should CrCl be used?

Answer 31

Cockcroft and Gault formula: (140-age) x weight x constant/ serum creatinine- age in years, weight in kg, serum creatinine in micromol/ litre, constant= 1.23 in men, 1.04 in women As an estimate of renal function for direct-acting oral anticoagulants (DOACs), and drugs with a narrow therapeutic index that are mainly renally excreted

Question 32

When should renal function and drug dosing be reassessed?

Answer 32

In situations where eGFR and/or CrCl change rapidly, such as in patients with AKI

Question 33

When is caution advised when using eGFR or CrCl to estimate renal function?

Answer 33

During AKI- as serum creatinine levels lag behind the development of the injury and progress of recovery. As creatinine rises, estimates of GFR will overestimate renal function and as creatinine falls and kidney function improves, estimates of GFR will underestimate renal function

Question 34

What formula is recommended for estimating GFR and calculating drug doses in most patients with renal impairment? Who should use this to routinely report eGFR?

Answer 34

CKD-EPI- adjusted for body surface area and utilises serum creatinine, age, sex and race as variables Clinical laboratories

Question 35

How does muscle mass affect eGFR? When should creatinine clearance or absolute glomerular filtration rate be used to adjust drug doses according to BMI?

Answer 35

Reduced muscle mass will lead to overestimation of GFR and increased muscle mass will lead to underestimation of the GFR In patients with a BMI less than 18 kg/m2 or greater than 40 kg/m2

Question 36

How is ideal and actual body weight used in CrCl?

Answer 36

Ideal body weight should be used to calculate the CrCl. Where the patient's actual body weight is less than their ideal body weight, actual body weight should be used instead

Question 37

How is ideal body weight calculated? Absolute GFR?

Answer 37

Constant + 0.91 (Height - 152.4) Constant = 50 for men; 45.5 for women Height in centimetres eGFR x (individual's body surface area / 1.73)

Question 38

Preferred method for estimating renal function in elderly patients aged 75 years and over? What is considered when thinking about using CKD-EPI?

Answer 38

Cockcroft and Gault formula Muscle mass

Question 39

When is the period of greatest risk during the 1st trimester? What can inhibit the infant's sucking reflex? Lactation?

Answer 39

From the 3rd-11th week Phenoarbital, bromocriptine

Question 40

What are STOPP/ START criteria?

Answer 40

Evidence-based criteria used to review medication regimens in elderly people

Question 41

Common adverse reactions in elderly patients?

Answer 41

Confusion- almost any of the commonly used drugs Constipation- antimuscarinics and many tranquilisers Postural hypotension and falls- diuretics and many psychotropics

Question 42

Hypoalbuminaemia in severe liver disease is associated with what? E.g.?

Answer 42

Reduced protein binding and increased toxicity of some highly protein-bound drugs such as phenytoin and prednisolone

Question 43

Efficacy and toxicity are closely related to what? Total daily maintenance dose of a drug can be reduced either by what or what? What is prolonged in renal impairment?

Answer 43

Plasma- drug concentration Reducing the size of the individual doses or by increasing the interval between doses The plasma half-life of drugs excreted by the kidney- it can take many doses at the reduce dosage to achieve a therapeutic plasma concentration

Question 44

How does the BNF identify drugs in relation to breast- feeding?

Answer 44

That should be used with caution or are contra-indicated in breast-feeding; that can be given to the mother during breast-feeding because they are present in milk in amounts which are too small to be harmful to the infant; that might be present in milk in significant amount but are not known to be harmful

Question 45

Who may become hypotensive under the stress of a dental visit?

Answer 45

Those with adrenal insufficiency

Question 46

What can be considered for moderate pain in palliative care? Alternatives to morphine? For pain--> bone mets?

Answer 46

Codeine phosphate or tramadol hydrochloride Transdermal buprenorphine/ fentanyl, hydromorphone hydrochloride, methadone hydrochloride, oxycodone hydrochloride Radiotherapy, bisphosphonates, radioactive isotopes of strontium chloride

Question 47

Options for neuropathic pain in palliative care? Due to nerve compression?

Answer 47

Gabapentin/ pregabalin, tricyclic antidepressant, ketamine under specialist supervision Dexamethasone/ nerve blocks or regional anaesthesia when localised to a specific area

Question 48

How is oral morphine given?

Answer 48

IR prep 4-hourly/ MR 12-hourly in addition to rescue doses- between regular doses additional dose of IR should be given + 30 minutes before activity that causes pain

Question 49

Standard dose of strong opioid for breakthrough pain? Increments of rescue morphine doses should not exceed what? Standard dose of immediate-release morphine? Once pain is controlled, patients can be transferred to what?

Answer 49

1/10th- 1/6th repeated every 2-4 hours as required 1/3 to 1/2 of the total daily dose every 24 hours 30mg 4-hourly, some up to 200mg 4-hourly or 100mg 12-hourly modified release/ 600mg The same total 24-hour dose of morphine given as the modified- release prep for 12 hourly

Question 50

When is the first dose of modified-release prep for 12-hourly morphine given? Monitor for what?

Answer 50

Within 4 hours of the immediate-release prep Constipation, and N&V

Question 51

Equivalent doses of opioid analgesics?

Answer 51

100mg codeine, 3mg diamorphine, 100mg dihydrocodeine, 2mg hydromorphone, 10mg morphine PO, 5mg morphine IM/ IV/ SC, 6.6mg oxycodone PO, 100mg tramadol PO

Question 52

Equivalent parenteral dose to oral dose? Route if can't swallow? Equivalent SC dose of diamorphine hydrochloride to oral morphine? Other morphine route?

Answer 52

Half of oral dose, SC infusion- diamorphine sometimes preferred as more soluble, can be given in a smaller volume 1/3 Rectal

Question 53

Who are transdermal preps of fentanyl and buprenorphine not suitable for?

Answer 53

Acute pain/ in those whose analgesic requirements are changing rapidly because the long time to steady state prevents rapid titration of the dose

Question 54

Reduce the calculated equivalent dose of the new opioid by how much compared to morphine? Morphine--> buprenorphine patch doses vs 'numbers'?

Answer 54

1/4 to 1/2 Morphine 12mg= '5' patch 24mg= '10' 36mg= '15' 48mg= '20' 84mg= '35' 126mg= '52.5' 168mg= '70'

Question 55

Formulations of transdermal patches are available as what options? Morphine-->fentanyl patch doses vs 'numbers'?

Answer 55

72-hourly, 96-hourly and 7-day patches 30mg= '12' 60mg= '25' 120mg= '50' 180mg= '75' 240mg= '100'

Question 56

Anorexia in palliative care can be helped by what? Bowel colic and excessive respiratory secretions? Given how often?

Answer 56

Prednisolone or dexamethasone SC injection of hyoscine hydrobromide, hyoscine butylbromide or glycopyrronium bromide- every 4 hours/ continuous infusion if sx persist, care to avoid dry mouth

Question 57

Capillary bleeding in palliative care treated with what? Tx discontinued when? Alternative? Consider what to prevent bleeding associated with prolonged clotting in liver disease in severe chronic cholestasis?

Answer 57

Tranexamic acid by mouth- one week after the bleeding has stopped/ continued at a reduced dose/ gauze soaked in tranexamic acid 100mg/mL or adrenaline solution 1mg/mL Parenteral/ water-soluble oral vitamin K

Question 58

What can be given for constipation in palliative care?

Answer 58

Faecal softener with a peristaltic stimulant/ lactulose solution with a senna prep, methylnaltrexone bromide for opioid-induced constipation

Question 59

How to prevent convulsions in patients with cerebral tumours or uraemia? When oral medication is not possible?

Answer 59

Phenytoin or carbamazepine Diazepam given rectally/ phenobarbital by injection

Question 60

Dry mouth associated with candidiasis can be tx how in palliative care? Tx for dysphagia? Breathlessness at rest? Dyspnoea ass w/ anxiety? If there's bronchospasm or partial obstruction?

Answer 60

Oral preps of nystatin or miconazole/ fluconazole Dexamethasone Regular oral morphine in carefully titrated doses Diazepam Dexamethasone

Question 61

What can be given for fungating tumours in palliative care?

Answer 61

Regular dressing and antibacterial drugs; systemic tx with metronidazole to reduce malodour, topical metronidazole= also used

Question 62

What can be given for pain of bowel colic in palliative care? Gastric distension due to pressure on the stomach?

Answer 62

Loperamide hydrochloride/ hyoscine hydrobromide given sublingually SC injections of hyoscine butylbromide, hyoscine hydrobromide and glycopyrronium bromide Antacid w/ an antiflatulent and a prokinetic e.g. domperidone

Question 63

Hiccup due to gastric distension in palliative care tx?

Answer 63

Antacid with an antiflatulent/ metoclopramide hydrochloride by mouth or by SC or IM injection, baclofen or nifedipine/ chlorpromazine hydrochloride

Question 64

What can be given for insomnia in palliative care? Intractable cough? Pain of muscle spasm?

Answer 64

Benzos such as temazepam Moist inhalations/ regular admin of oral morphine Muscle relaxant such as diazepam or baclofen

Question 65

1st line therapy for N&V? May occur with what particularly in the early stages?

Answer 65

Prokinetic- metoclopramide hydrochloride or haloperidol (usually only for first 4 or 5 days) Opioid therapy

Question 66

Metoclopramide hydrochloride is used by mouth for N&V associated with what? Haloperidol? Cyclizine? Levomepromazine? Dexamethasone?

Answer 66

Gastritis, gastric stasis and functional bowel obstructions Most metabolic causes of vomiting e.g. hypercalcaemia, renal failure N&V due to mechanical bowel obstruction, raised ICP, and motion sickness By mouth/ SC at bedtime (review antiemetics every 24 hours)

Question 67

Pruritus in palliative care tx? Headache due to raised ICP?

Answer 67

Emollients, colestyramine Dexamethasone before 6pm to reduce the risk of insomnia

Question 68

Restlessness and confusion in palliative care tx? What should be considered?

Answer 68

Antipsychotic- e.g. haloperidol or levomepromazine by mouth/ SC injection both repeated every 2 hours if required A regular maintenance dose given x2 daily by mouth / SC injection; continuous infusion device

Question 69

Indications for parental administration of drugs in palliative care?

Answer 69

The patient is unable to take medicines by mouth owing to nausea and vomiting, dysphagia, severe weakness, or coma there is malignant bowel obstruction in patients for whom further surgery is inappropriate (avoiding the need for an intravenous infusion or for insertion of a nasogastric tube) Occasionally when the patient does not wish to take regular medication by mouth

Question 70

Antiepileptic of choice for continuous SC infusion to prevent convulsions? What else?

Answer 70

Midazolam Haloperidol and levomepromazine- sedation can limit the dose of levopromazine

Question 71

How can ocreotide be used in palliative care?

Answer 71

By SC infusion to reduce intestinal secretions and to reduce vomiting due to bowel obstruction

Question 72

What can be mixed with diamorphine for a SC infusion in a strength of up to 250mg/mL? Why should SC infusion solution be monitored regularly?

Answer 72

Cyclizine, dexamethasone, haloperidol, hyoscine butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide, midazolam To check for precipitation and to ensure that the infusion is running at the correct rate

Question 73

Drugs causing delirium/ acute confusion in the elderly? Dehydration? Renal impairment? Liver impairment?

Answer 73

Sedative hypnotics- benzos like diazepam, zopiclone, analgesics, anticholinergics, anticonvulsants, antidepressants, antipsychotics, metoclopramide, electrolyte imbalance e.g. hyponatraemia from thiazide like diuretics Diuretics Withheld metformin NSAIDs, corticosteroids worsening oedema/ ascites, rifampicin

Question 74

Issues encountered with syringe drivers?

Answer 74

If the subcutaneous infusion runs too quickly check the rate setting and the calculation; if the subcutaneous infusion runs too slowly check the start button, the battery, the syringe driver, the cannula, and make sure that the injection site is not inflamed; if there is an injection site reaction make sure that the site does not need to be changed—firmness or swelling at the site of injection is not in itself an indication for change, but pain or obvious inflammation is

Question 75

Groups of drugs used to treat Parkinson's?

Answer 75

Levodopa drugs & dopa-decarboxylase inhibitor e.g. Co-careldopa, Madopar COMT inhibitors e.g. entacapone, tolcapone MAO inhibitors e.g. selegiline, rasagiline Dopamine receptor agonists e.g. ropinirole (modified release/ immediate release,) pramipexole

Question 76

What is in co-careldopa? Madopar? Function of levodopa? Carbidopa? Benserazide?

Answer 76

Levodopa + carbidopa Levodopa + benserazide Helps to replace the missing dopamine/ prevents levodopa from being broken down before reaching the brain/ prevents levodopa changing to dopamine in the bloodstream- more can enter the brain

Question 77

What is adherence? What is compliance? Concordance?

Answer 77

The extent to which the patient's medicines- taking behaviour matches agreed recommendations from the prescriber The extent to which the patient's medicines-taking behaviour matches the prescriber's recommendations The belief that the prescriber and the patient must come to an agreement regarding therapeutic decisions- more likely to result in adherence with the prescriber's recommendations

Question 78

WHO has determined that what 5 interacting dimensions affect adherence?

Answer 78

Social/ economic factors, health system/ healthcare team factors, therapy-related factors, patient-related factors, condition-related factors

Question 79

Thiazide diuretics can cause what? Systemic corticosteroids may alter what? Prochlorperazine can cause what?

Answer 79

Hyperuricaemia which may exacerbate gout in suspectible patients Mood and behaviour- needs a therapy review, reduction or discontinuation would depend on the indication for tx Extra-pyramidal side effects e.g. dystonia, review & switch if possible

Question 80

May be cheaper for patients to buy a what if they have to pay for more than 11 prescribed medicines each year/>3 medicines in 3 months?

Answer 80

A Prescription Pre-Payment Certificates (PPC)- spreads the cost of prescriptions across 12 months (or 3 months)

Question 81

What is the New Medicine Service (NMS)? Patients prescribed a new medicine on one of the following are eligible for the NMS?

Answer 81

Pharmacy-based intervention which provides support for people with long-term conditions who are newly prescribed a medicine Asthma & COPD, T2DM, antiplatelet/ anticoagulant therapy, HTN

Question 82

Factors affecting bioavailability? Key pharmacokinetic parameters that describe bioavailability? What is steady-state concentration?

Answer 82

Route of administration, properties of the drug, plasma-protein binding, metabolism, elimination Area under the curve(AUC,) peak plasma concentration (Cmax,) time to peak plasma concentration (Tmax) When the inflow of the drug into plasma is equal to the rate of removal

Question 83

How is the volume of distribution/ apparent volume of distribution (Vd) worked out? What will it depend on?

Answer 83

Total amount of drug in the body(X)- mg/ plasma-drug concentration (Cp)- mg/ litre- typically reported in (ml or litre)/ kg body-weight The physiochemical properties of the drug and the individual's patient's body composition

Question 84

Which drugs have a low Vd? Larger Vd?

Answer 84

Highly water soluble ones like gentamicin, atenolol, and insulin/ extensively protein-bound e.g. warfarin- stay in the plasma Highly lipid soluble e.g. digoxin, morphine and diazepam- go out of the plasma into tissues and organs

Question 85

Acidic drugs bind to what? Basic drugs bind to what? Acronym for hepatic clearance? Renal clearance? Total body clearance is calculated how?

Answer 85

Albumin Alpha1-acid-glycoprotein CLH, CLR, CL= CLH + CLR

Question 86

The pharmacokinetics of a drug can be defined using how many parameters? How is the elimination rate constant(k) calculated?

Answer 86

3: volume of distribution (vd,) elimination half-life(t1/2,) clearance(Cl) k= Cl/ Vd- the greater the fraction of drug removed in unit time, the shorter the half-life, half-life varies inversely with elimination rate constant (k)

Question 87

Vd can be significantly altered by what? Vd equation? Half-life?

Answer 87

Alterations in plasma-protein concentrations, hepatic disease; and changes in patient physiology- these help determine the time taken for a drug to reach steady-state concentration Vd= X/ Cp, X= amount of drug in body and Cp= plasma concentration Half-life= 0.693/k where 0.693 is ln2, the natural logarithm of 2

Question 88

What can the therapeutic window help to determine?

Answer 88

Whether a drug concentration is ineffective, effective or toxic- monitoring needed for drugs with a narrow therapeutic window e.g. digoxin, gentamicin, lithium salts, vancomycin

Question 89

Approximately how many half lives needed to excrete 97% of a drug?

Answer 89

5 half-lives

Question 90

Chemical formula for a drug with its receptor? The proportion of receptors occupied by a drug is equal to what? What is Kd?

Answer 90

D+R<--> DR p= [D]/ [D] + Kd- the Hill-Langmuir equation The ratio k-/k+ (the forward rate or reverse rate constant)

Question 91

Most antagonists are what?

Answer 91

Competitive- increasing this concentration right-shifts the curve, decreasing binding for a fixed agonist concentration

Question 92

What is affinity? Efficacy?

Answer 92

The tendency of a molecule to bind to a receptor following occupancy of this receptor How well an agonist achieves a response- it can encompass a very complex pathway

Question 93

What is the potency of a drug often described by?

Answer 93

The concentration/ dose that is able to elicit 50% of the maximal response i.e. the EC50/ ED50- a drug with higher potency achieves that size of response at a lower concentration

Question 94

What is a partial agonist? E.g.?

Answer 94

A drug that has a lower maximal response resulting from lower efficacy Many of the 'beta blockers'

Question 95

What do allosteric modulators do?

Answer 95

Bind to proteins at sites other than the binding site for the principal agonist- can alter the affinity of the binding site for its agonists/ change the efficacy of the response when the agonist binds Can be positive- increase the potency of the agonists/ negative- decrease the potency of an agonist

Question 96

What does early pregnancy body-weight relate to? Actual body weight? Used when?

Answer 96

The patient's weight in their first trimester The weight you get when you stand the patient on a set of scales- product requires the dose to be calculated on a 'per kilogram' basis but does not specify a type of weight to use

Question 97

What is ideal body weight derived from? How is lean body weight calculated? What do drugs distributed in water need to be dosed based on? Distribute into fat? For patients at the extremes of the weight range?

Answer 97

Insurance date By subtracting body fat weight from actual body weight Lean or ideal body weight; actual body weight Seek further information on appropriate dosing, particularly of those drugs with a narrow therapeutic index

Question 98

Equations for calculating a child's weight in 0-12 months, 1 to 5 years, 6-12 years?

Answer 98

(0.5 x age in months) + 4(kg) (2 x age in years) + 8(kg) (3x age in years) + 7 (kg)

Question 99

What does a 1% w/w preparation mean? Hydrocortisone 0.5% w/w? 1% w/v solution? 1% v/v solution?

Answer 99

1g of drug in 100g of the final product 0.5g of hydrocortisone in 100g of the cream 1g of drug in 100mg of the final product 1ml of liquid in 100ml of the final product

Question 100

1:1000 represents what? 1:10,000? Adrenaline 1 in 1000? 1 in 200,000?

Answer 100

1 gram in 1000ml/ 1 gram in 10,000ml 1 mg per ml , 5 mcg per ml

Question 101

How many lbs in a stone? Grams in a pound? How many kg is 1 stone? Inches in one foot? Mm in 1 inch? Mm in 1 foot?

Answer 101

14 pounds, 450g, 6.35kg 12 inches, 25.4mm, 304.8 mm

Question 102

Up to what age is classed as a neonate? Infant? Adolescent?

Answer 102

1 month, up to 1 year (,then 1-5 years, 6-11 years,) 12-16 years

Question 103

Doses of chlordiazepoxide, lorazepam, nitrazepam and temazepam that are equivalent to 5mg diazepam?

Answer 103

12.5mg, 500mcg, 5mg, 10mg

Question 104

What dose does hydrocortisone compare to prednisolone?

Answer 104

x4 e.g. 100mg hydrocortisone= 25mg prednisolone

Question 105

Max body weight to be used for acetylcysteine? Preferably diluted in what? First dose is given over how long in how much of glucose 5%? Second dose? Third and final dose? Doses needed each dose? Alternative?

Answer 105

110kg- even if the patient is heavier i.e. the dose is capped Glucose 5%- NaCl 0.9% if glucose 5% is not suitable 1 hour in 200ml of glucose 5%, 2) the next 4 hours in 500ml glucose 5%, 3) 3rd and final= over the next 16 hours in 1 litre of glucose 5% 1) 150mg/kg, 2) 50mg/ kg, 3) 100mg/ kg= 300mg/ kg over 21 hours In millilitres according to defined weight bands

Question 106

Acetylcysteine is most useful given in what time period?

Answer 106

8 hours

Question 107

In clinical practice, the dose of immunoglobulins is often rounded to what?

Answer 107

The nearest 5g

Question 108

How do you calculate the volume of a parenteral drug needed to be administered or added to an infusion?

Answer 108

(Dose prescribed x volume of solution)/ amount of drug in solution

Question 109

What is warfarin the anticoagulant of choice for? What does dabigatran inhibit? Rivaroxaban, apixaban and edoxaban?

Answer 109

The prevention of thromboembolic events in patients with mechanical heart valves and valvular AF and patients in end-stage renal failure Thrombin Activated factor Xa

Question 110

Contraindications for warfarin?

Answer 110

Malignancy- use heparin/ a DOAC, known hypersensitivity to warfarin, haemorrhagic stroke, clinically significant bleeding, potential bleeding lesions, uncorrected major bleeding, pregnancy- risk of congenital malformations and fetal death, within 72 hours of major surgery with the risk of severe bleeding, within 48 hours postpartum, uncontrolled severe HTN, patient factors, drugs with increased risk of bleeding- NSAIDs, antiplatelets, enzyme inhibitors

Question 111

INR treatment targets when taking warfarin? How long for?

Answer 111

2-3 for tx of VTE, AF, mitral valve disease and inherited symptomatic thrombophilia 2.5-3.5 for mechanical heart valves Usually lifelong - exception= tx of VTE if temporary RFs prior to clot--> 3 months, if permanent- 6 months

Question 112

How long may warfarin take to achieve an INR within the therapeutic range? What does it induce? How is this addressed?

Answer 112

5 days A hypercoagulable state- suppression of protein C occurs quicker than that of the coagulation factors(shorter half-life) If patient develops an acute VTE and high risk of further thrombosis- admin of heparin considered for at least 5 days until INR within therapeutic range

Question 113

Most common SE of warfarin? Exclude what following a head injury? Other SEs?

Answer 113

Haemorrhage, IC haemorrhage Hypersensitivity, rash and alopecia

Question 114

Options for reversing warfarin?

Answer 114

Withholding warfarin, vitamin K, either orally or intravenously, prothrombin complex concentrate(PCC,)(containing factors II, VII, IX & X= 4-factor PCC, without factor VII= 3-factor PCC) Fresh frozen plasma of PCC unavailable Often mixture of above= considered- use of PCC/ FFP depends on INR + bleeding severity

Question 115

What things induce the action of warfarin? Inhibitors? Many what interact with warfarin and should be checked before starting?

Answer 115

Alcohol, allopurinol, paracetamol, SSRIs, lipid-regulating drugs, influenza vaccine Oral contraceptives and St John's wort Antibiotics

Question 116

For surgeries with a high risk of bleeding, warfarin should be held ideally for how long prior and INR checked when? What can be used to bridge the gap? In severe renal impairment and extremes of weight? Why? When does this bridging take place?

Answer 116

5 days, before/ on the day of surgery LMWH, UFH- due to its short activity and reversibility in case of bleeding 3 days prior- LMWH= discontinued 1 day prior to procedure and UFH 6 hours

Question 117

When should INR be checked? When can warfarin be recommenced? Foods high in vitamin K? What can enhance warfarin's anticoagulant effect?

Answer 117

The day prior to the procedure, once surgical haemostasis has been achieved + oral meds can be tolerated- bridging w/ heparin post-operatively may be required in patients at high risk of TE Green leafy vegetables, liver, eggs, avocado, olive oil Cranberry juice

Question 118

When are blood tests done to monitor warfarin? How should warfarin be taken?

Answer 118

Initially every 3-4 days until 2 consecutive readings are within range, then x2 weekly for 1-2 weeks until 2 consecutive readings are in range At the same time each day to keep the levels of warfarin steady- if a dose if forgotten, take it as soon as remembered, don't realise until following day= skip the missed dose

Question 119

What is arthrotec (diclofenac) contraindicated in? Things to consider appropriate formulation for a child?

Answer 119

Post-stroke Age and developmental stage of the child, acceptability and palatability, frequency of dosing, ease of administration, convenient and reliable administration, impact on lifestyle, minimum exposure to excipients, whether the formulation can deliver doses variable to age/ weight/ BSA, route of admin needs to be acceptable to the child and their parents/ carers

Question 120

What advice is given when taking medications alongside colestyramine?

Answer 120

Take them either 1 hour before or 4-6 hours after the colestyramine

Question 121

How long is morphine's half life? Remifentanil? Medicines that should be prescribed and administered by brand name?

Answer 121

4-6 hours, minutes Diltiazem preps, some antiepileptics, lithium salts, theophylline preps, some immunosuppressant therapies e.g. tacrolimus

Question 122

3 categories of unlicensed preparations of drugs?

Answer 122

1) The medicine is produced and licensed in another country and imported 2) Medicine is unlicensed and produced in a licensed manufacturing unit in this country 3) The medicine is unlicensed and produced in an unlicensed manufacturing facility e.g. such as a pharmacy department

Question 123

What is a 'special'? Patient factors to consider when you prescribe a medicine?

Answer 123

An unlicensed preparation of a medicine- liquid or powder versions of a solid oral dosage form specifically intended for patients who have swallowing difficulties, may include topical preparations- not usually on the BNF, contact a pharmacist for advice The excipients, monitor the patient and note any change in their clinical status

Question 124

How to take levothyroxine? Simvastatin? How should standard release nitrates be prescribed? Parkinson's meds?

Answer 124

In the morning before breakfast, at night So that there is a "nitrate free period" of at least 8 hours - ideally at least 10 hours- prevents the patient developing a tolerance According to the patient's usual dosing regimen- late admin can result in 'end of dose failure' + return of sx before the next dose

Question 125

How should timolol standard release eye drops be prescribed and administered?

Answer 125

At 12 hour intervals- failure may result in the glaucoma becoming difficult to control--> sight loss

Question 126

Only what values can be abbreviated? It is not a legal requirement to do what regarding someone's DOB? What patient details needed?

Answer 126

Grams and milligrams (g) and (mg) It isn't a legal requirement on an inpatient drug chart- legal requirement to include age/ DOB if the patient is under 12 y/o Full name and address- hospital number in hospital setting, a valid date, my signature, my address, in indelible ink

Question 127

F1 doctors are not permitted to prescribe what? How to know if they're controlled? Examples of correct total quantities or number of dosage units?

Answer 127

Controlled drugs Schedule 2 and 3 preparations= CD2 or CD3 next to them in the BNF- all under "Controlled drugs and drug dependence" Morphine sulfate MR capsules 10mg BD, supply 14(fourteen capsules) Morphine sulfate concentrated oral solution 100mg/5ml, 1ml four times a day when required for breakthrough pain, supply 30(thirty) mls

Question 128

It's recommended that quantities of controlled drugs don't exceed what? Meaning of opioid naive? Licensed medicines in the UK have been granted what? This classifies licensed drugs into what 3 classes?

Answer 128

30 days A patient has not used opioids for more than seven consecutive days during the previous 30 days General Sales List medicines(GSL)- general sale Pharmacy Medicines(P)- through pharmacies only Prescription Only Medicines(POM)- registered practitioners only Controlled drugs(CD)- registered practitioners only, restrictions on supply apply to some NMPs

Question 129

What do unlicensed products not have? What is off-label prescribing?

Answer 129

A UK marketing authorisation The use of a drug that does have a marketing authorisation- its use is outside the terms of its licence- may be at a different dose, indication, or patient group outlined in the 'Summary of Product Characteristics'(SPC)

Question 130

If you choose to prescribe multiple routes, check that change in routes does not affect what? What do consider when reviewing prescriptions?

Answer 130

The dose Review all medication regularly, stop any unnecessary medication, consider documenting review dates, both within the patient's notes and on the inpatient

Question 131

How to cancel a prescription on an inpatient drug chart? When amending a dose/ frequency?

Answer 131

Cross through the entire entry, annotate the entry with your signature and a date, do not obliterate it entirely, document any changes in the medical notes- including the rationale Re-write in full, make an entry in the medical notes

Question 132

3 stages to medicine reconciliation?

Answer 132

1) Verification- collect info from recent and accurate sources to verify the drug hx 2) Clarification- check this against the current list of medicines prescribed in hospital 3) Reconciliation- document any discrepancies, changes and omissions, whether intentional or unintentional

Question 133

St John's Wort can reduce the concentration of what? Garlic, feverfew, Echinacea and ginseng can inhibit what? Common omissions in a drug history? Good mnemonic?

Answer 133

Lansoprazole, platelet aggregation Borderline substances e.g. vitamins, food supplements, contraceptives, eye/ ear drops, herbal medicines and homeopathic therapies, inhalers, injections, recreational drugs, topical preparations DRUGS: drugs by registered practitioner, recreational, user- OTC/ complementary, gynaecological, COCP/ HRT, sensitivities- sensitivities and the nature of the reaction

Question 134

Sources of the drug history?

Answer 134

At least 2 sources of information- ideally the patient and their drugs= primary sources- also GP, carers, community pharmacist, medical notes + electronic prescribing records, NHS Summary Care Record(SCR)

Question 135

What are warfarin tablets available as?

Answer 135

500 micrograms(white,) 1 mg (brown,) 3 mg (blue,) and 5mg(pink)

Question 136

How is hydroxocobalamin (vitamin B12) given? Goserelin?

Answer 136

Every 2 or 3 months for maintenance therapy Monthly/ 3 monthly

Question 137

What does an upside down black triangle signify? All suspected ADRs to a black triangle must be what?

Answer 137

A medicine is being closely monitored by the Medicines and Healthcare Products Regulatory Agency(MHRA) for adverse effects- all medicines with a new active substance and all new biologics, medicines that require further information after licensing, medicines subject to conditions/ restrictions on safe and effective use Reported

Question 138

What is meant by an unlicensed medicine? Off-label?

Answer 138

One that has not been subject to the licensing process- does not have a UK Marketing Authorisation authorised by the MHRA One that is licensed in the UK, but is being outside the terms of its Marketing Authorisation e.g. one for adults used for a child/ used for an indication not stated in the Marketing Authorisation, administered via a route other than that stated in the licensed way

Question 139

You must be satisfied of what when prescribing an unlicensed medicine?

Answer 139

There are no suitable licensed alternatives that would meet the patient's needs, there is sufficient evidence base and/ or experience for using the unlicensed medicine, you must be prepared to take responsbility for prescribing the unlicensed medicine and for overseeing the patient's care+ monitoring, your decision has been documented in the medical notes including the rationale for the prescription

Question 140

For renal impairment in children, the eGFR is calculated using what? For a neonate and child over 1 month?

Answer 140

The modified Schwartz equation 30 x height (cm)/serum creatinine (micromol/litre) 35 x height (cm)/serum creatinine (micromol/litre)

Question 141

Information pertaining to the electrolyte and/ or excipient content of a formulation is listed under what? E.g. of excipients to be aware?

Answer 141

The medicinal forms within a monograph Alcohols, artificial preservatives/ sweeteners- aspartame/ saccharin, diluents/ vehicles- arachis/ peanut oil, electrolytes- sodium/ potassium, lactose, sensitising agents e.g. beeswax, sorbic acid, parabens

Question 142

A Yellow Card is submitted for what?

Answer 142

All serious ADRs that result in harm and suspected ADRs to new drugs and vaccines

Question 143

What is often used to identify patients with an allergy? Type I allergic reactions usually occur within how long of exposure to the triggering drug? Median time to cardiac arrest in fatal drug-induced anaphylaxis? Typical allergic sx?

Answer 143

A red allergy alert band or red identification bracelet Minutes- 2 hours, 5 minutes Itching, urticaria, hypotension, angiodema, wheeze

Question 144

What are fixed drug eruptions? Causes?

Answer 144

Erythematous plaques that recur in the same place each time the causative drug is taken Paracetamol, tetracyclines and NSAIDs

Question 145

Prescribe what cautiously when someone has experienced pronounced allergic reactions with penicillins? You can safely prescribe what to patients with a history of penicillin allergy? Advice on individual vaccines and patients for whom they may be contraindicated is kept to date in what?

Answer 145

Cephalosporins and carbapenems Aztreonam The "Green book"

Question 146

Factors that might increase the risk of developing an allergic reaction to a drug?

Answer 146

Atopic individuals: more severe reactions, more likely to react to radiocontrast media Co-existing conditions: HIV, EBV, CMV and CF= increased risk of drug allergy Chronic urticaria or mastocytosis- may be sensitive to NSAIDs, opioid analgesics, and other drugs with histamine releasing properties such as atracurium Drug dependent factors: Beta-lactam antimicrobials, NM blocking agents- NMBAs, radiocontrast media, NSAIDs, high molecular weight starches Frequent and prolonged doses Women>men Topical treatments

Question 147

What might decrease the risk of allergic drug reactions? Common causes of allergic drug reactions?

Answer 147

Use of low osmolarity agents and pre-dosing with corticosteroids and antihistamines in high risk patients Chlorhexidine, opioid analgesics, non beta-lactam antimicrobials, NSAIDs, muscle relaxants, opioid analgesics, penicillins and other beta-lactams, plasma expanders, radiocontrast media

Question 148

Agents that are causes of allergic reactions during anaesthesia? What can aggravate patients with pre-existing urticaria?

Answer 148

Antimicrobials- notably co-amoxiclav & teicoplanin, chlorhexidine, colloids, NM blocking agents, patent blue injection, miscellaneous medicines NSAIDs and opiates- based on COX-1 enzyme inhibition

Question 149

In patients with no evidence of systemic reaction, administration of what should be sufficient? What should be available in case of a moderate to severe reaction? Evidence of a severe reaction?

Answer 149

Fast-acting oral antihistamine- chlorphenamine= quick acting and effective H1 antihistamine oral/IV/ IM IM adrenaline Hypotension, laryngeal oedema, wheeze, SpO2<92%, impaired consciousness

Question 150

What should the Sampson severity score(mild--> severe anaphylaxis) be based on? Doses of adrenaline used in adults, children aged 6-12 years old and children younger than 6 years old? Followed by what doses of IV chlorphenamine in adults/>12 y/o, children 6-12 y/o, children 6 months- 6 years, children <6 months old, as well as hydrocortisone?

Answer 150

The organ system most affected 500mcg/ 300 mcg/ 150 mcg 10mg/ 5mg/ 2.5mg/ 250mcg/kg

Question 151

Doses of hydrocortisone for anaphylaxis in adults/ children>12 y/o, children 6-12 y/o, children 6 months- 6 y/o and children < 6 months y/o?

Answer 151

200mg/ 100mg/ 50mg/ 25mg

Question 152

Inhaled/ IV what can be used in the management of anaphylaxis? Other examples of bronchodilators? What to prescribe after all moderate to severe anaphylactic reactions to a medicine?

Answer 152

Salbutamol/ ipratropium, aminophylline, magnesium Prednisolone for up to 3 days, a non-sedating antihistamine for up to 3 days, medical alert band if re-exposure is possible, document the allergy in the medical notes and on the drug chart, communicate to the GP, warn if if in OTC drugs, provide structured written info to the patient, x2 adrenaline auto-injectors for self-administration only significant risk of re-exposure, report--> Yellow card scheme

Question 153

Refer patients with a drug allergy to a specialist centre for further advice and possible Ix in what following scenarios? Who are adrenaline auto-injectors prescribed for? What is done after every use even if sx are improving? 3 auto-injectors available?

Answer 153

All severe reactions, during/ after general anaesthesia, when future management may be complicated by unnecessary avoidance of the medicine Those at an increased risk of an idiopathic anaphylactic reaction/ high risk of exposure to anaphylactic triggers e.g. venom stings, food Ambulance, lie down with legs raised to maintain blood flow, breathing issues- sit up EpiPen, Emerade, Jext

Question 154

When should timed blood samples for mast cell tryptase be taken for drug allergies? Observed for how long from the onset of sx if they have received emergency tx and an adult/ child aged 16 y/o or older? When is a mast cell tryptase level helpful and not helpful?

Answer 154

ASAP after emergency tx has started and 1-2 hours after the onset of sx and 24 hours if possible - document drug allergy status separately from ADRs, refer to a specialist allergy service if appropriate 6-12 hours- admit under Paeds if child< 16 y/o Not if the patient has had the cardinal S&S of an allergic reaction, is in suspected reactions during anaesthesia

Question 155

Skin prick testing can be done to see if a drug can be administered if what drugs which prevent its effect like what haven't been recently given? What can give false positives? What's used to confirm true positive responses?

Answer 155

Antihistamines, H2 receptor antagonists, older antidepressants, systemic corticosteroids, topical corticosteroids Non-specific histamine release(opiates, NSAIDs, NMBAs) or irritation (e.g. erythromycin) Intradermal injections at dilutions determined by challenge studies

Question 156

5 Rs when prescribing IV fluids? Assessment and monitoring of someone's fluid status?

Answer 156

Resus, routine maintenance, replacement, redistribution and reassessment Hx: previous limited intake, the quantity and composition of abnormal losses, comorbidities Exam: pulse, BP, CRT, JVP, pulmonary/ peripheral oedema, presence of postural hypotension Monitoring: NEWS, fluid balance charts, weight Lab Ix: FBC, urea, creatinine and electrolytes Daily reassessments, lab values and fluid balance charts + weight measurement x2 weekly

Question 157

Signs that someone is hypovolaemic and needs IV fluid resus? If receiving IV fluids for resus, reassess using what and monitor what?

Answer 157

Systolic BP<100mHg, HR>90 bpm, CRT>2 seconds/ peripheries= cold to touch, RR>20 breaths per minute, NEWS= 5 or more, passive leg raising test is positive The ABCDE approach- RR, pulse, BP and perfusion continuously, venous lactate levels and/ or arterial pH and base excess according to guidance on ALS

Question 158

If receiving IV fluids w/ chloride concs> 120mmol/l, monitor what? Consider human albumin solution only for resus in who? Adjust to what for obese patients? Consider less fluid for who?

Answer 158

Their serum chloride concentration daily Patients with severe sepsis Their ideal body weight Those with renal impairment or cardiac failure / older or frail/ malnourished and at risk of refeeding syndrome

Question 159

Consider using what when prescribing for routine maintenance alone? Greater than what risk hyponatraemia?

Answer 159

25-30ml/kg/day NaCl 0.18% in 4% glucose with 27 mmol/l potassium on day 1 2.5 litres

Question 160

Intracellular fluid has what? Extracellular fluid? EC fluid consists of what? Protein conc is much lower in what compartment? Other force affecting fluid movement between these x2 areas?

Answer 160

High K+ conc, low Na+ conc, intracellular solute concs remain more or less constant High Na+ conc, low K+ conc- interstitial and intravascular fluid, interstitial fluid Hydrostatic pressure from circulatory pressures, oedema etc.

Question 161

Aim for what urine output in fluid replacement? Lost by faeces? Insensible losses? Other?

Answer 161

0.5ml/kg/ hour 100ml/ day, 500-800ml per day Bleeding, burns

Question 162

Sweating leads to what? Diarrhoea/ increased stoma output? Vomiting? Insensible losses?

Answer 162

Sodium loss Sodium, potassium and bicarbonate Potassium, chloride and hydrogen ions--> hypochloraemic metabolic alkalosis Pure water loss

Question 163

Where does isotonic fluid stay? What does hypertonic solutions do? Hypotonic? How does 1000ml NaCl distribute?

Answer 163

Almost entirely within the EC compartment e.g. NaCl 0.9% Increase plasma tonicity- draw fluid out of cells e.g. NaCl 3%, mannitol Lower serum osmolarity e.g. NaCl 0.45% 75%--> interstitial compartment, 25%--> intravascular(both EC)

Question 164

How does 1000ml of glucose 5% distribute?

Answer 164

2/3--> IC fluid, 1/3--> EC fluid, 80ml of EC fluid--> intravascular compartment

Question 165

How does 1000ml human albumin solution distribute? What are 1st line for fluid resus and maintenance?

Answer 165

1000ml stays in the intravascular compartment Crystalloids w/ sodium in the range 131-154 mmol/ litre 0.9%

Question 166

Medical therapies for fluid overload? 4 Ds of fluid therapy?

Answer 166

Stop IV fluids, furosemide- bolus/ infusion, sublingual nitrate, IV nitrate- needs BP monitoring, CPAP Drug, dose- quantity/ rate, duration- START + review date, de- escalation- when to STOP

Question 167

Clinical presentation of rhabdomyolysis? RFs? How does diltiazem affect simvastatin?

Answer 167

Muscle swelling, tenderness and weakness, urine= grey-brown due to myoglobin, CK= raised by up to 10-100 times the normal limit Associated with renal failure- myoglobin precipitates in the renal tubules, also hyperkalaemia as K+ is release when muscle cells break down Increased age, female, genetic predisposition, pre-existing renal impairment It inhibits its metabolism by inhibiting the cytochrome P450 isoenzyme CYP3A4- increases toxicity risk

Question 168

What is an adverse event? ADR?

Answer 168

Any harmful or unpleasant event that patient experiences while using a drug, whether or not it is related to the drug Adverse event where it is suspected to be cause by the drug

Question 169

What is a Type A ADR? Type B? C? D? E? F?

Answer 169

Dose-related, common, predictable, related to the pharmacology, unlikely to be fatal e.g. digoxin toxicity/ constipation with opioid analgesics Not dose-related, uncommon, unpredictable, not related--> pharmacology, often fatal e.g. penicillin hypersensitivity, malignant hyperthermia and hepatitis from anaesthetic agents Uncommon, related to cumulative dose, time-related Delayed- uncommon, usually dose-related, occurs/ becomes apparent some time after use of the drug e.g. carcinogenesis End of tx- uncommon, soon after withdrawal of drug e.g. opiate withdrawal syndrome

Question 170

3 ADR types according to dose?

Answer 170

Hypersusceptibility- at doses lower than therapeutic, Collateral effects- at therapeutic doses Toxic effects- at doses higher than those used therapeutically

Question 171

2 ADR types based on time? Based on time course x6?

Answer 171

Dependent/ independent- any time during the drug tx, may be triggered by something changing drug conc within the body Rapid reactions, early reactions, first dose reactions, intermediate reactions, late reactions, delayed reactions

Question 172

Mnemonic for susceptibilities for ADRs?

Answer 172

IGASPED: immunological reactions e.g. allergies, genetics, age, sex, physiology, exogenous- other drugs/ foods/ temperature, disease states affecting the patient

Question 173

What do neonates have? How does metoclopramide affect children/ young adults and older adults?

Answer 173

Higher body-water content, reduced albumin and total protein, immature BBB Increased risk of dystonic adverse effects/ Parkinsonism

Question 174

Conditions that increase the risk of ADRs?

Answer 174

Congestive HF, diabetes mellitus, chronic pulmonary disease, rheumatological and malignant disease

Question 175

E.g. drugs more common in females> males?

Answer 175

Psych adverse effects with the anti-malarial mefloquine, drug-induced torsade de pointes--> VF + death(women= longer QT interval,) hyponatraemia with diuretics

Question 176

E.g. of how ethnicity affects drug metabolism?

Answer 176

CYP2C9 allele- more frequently defective in those of European origin, Afro-Caribbean= angioedema with the use of ACE-i, Chinese + Japanese= less psych effects from mefloquine than European/ African origin, increased myopathy risk in Asian origin

Question 177

Abacavir(antiretroviral) causes severe hypersensitivity reactions mostly in those with what? (Also increased risk of SJS & TEN in use of carbamazepine, phenytoin, oxcarbazepine & lamotrigine)

Answer 177

HLA-B*5701 allele

Question 178

G6PD causes an increased risk of what? More in who? Risk and severity related to what? Drugs that pose a risk?

Answer 178

Drug-induced haemolytic anaemia- men and Mediterranean, tropical Africa, and Asia Drug dose and precise gene mutation Anti-malarials, nitrofurantoin, quinolone antimicrobials, rasburicase, sulphonamides e.g. co-trimoxazole

Question 179

What is acute porphyria? Patients with this differ how? What is clozapine associated with? How is the risk of blood dyscrasias reduced with methotrexate? Serum- lithium levels taken when?

Answer 179

Inherited disorder of haem biosynthesis- in their responses to medicines Agranulocytosis(monitor WBCs, platelets and neutrophils) FBC, renal and LFTs at baseline, weekly until therapy has stabilised and then every 2-3 months thereafter Every 3 months

Question 180

4 things needed to submit a vlid report to the Yellow Card scheme? 4 sources for info on ADRs?

Answer 180

Identified patient e.g. hospital number, suspected reactions, suspected drug, reporter BNF, MHRA, Electronic Medicines Compendium, UK Medicines Information Service

Question 181

When is 'red man syndrome' seen?

Answer 181

When vancomycin is given as bolus injection rather than over at least 60 minutes

Question 182

How should hypotension be corrected in poisoning? What is common after prolonged coma and aspirin poisoning? HTN associated with what drugs?

Answer 182

Raising the foot of the bed and administration of an infusion of either NaCl or a colloid Fluid depletion due to vomiting, sweating and hyperpnoea Sympathomimetic drugs e.g. amphetamines, phencyclidine, and cocaine

Question 183

How should an obstructed airway in poisoning in the absence of trauma be managed? Consider intubation and ventilation in who? What may be needed? When should O2 be given?

Answer 183

Chin lift or jaw thrust, oropharyngeal/ nasopharyngeal in those with reduced consciousness Airway can't be protect/ those with respiratory acidosis Mouth-to-mouth or bag-valve-mask device In the highest conc in carbon monoxide poisoning and irritant gases

Question 184

Cardiac conduction defects and arrhythmias common with the use of what drugs? Hypothermia? Hyperthermia?

Answer 184

Tricyclic antidepressants, some antipsychotics and some antihistamines- seek advice with QT interval prolongation Those who have been deeply unconscious for some hours- particularly following overdose with barbiturates or phenothiazines- prevent further CNS stimulants- remove unnecessary clothing and fan, sponging with tepid water

Question 185

What convulsions don't require tx? Those that are protracted or recur frequently?

Answer 185

<5 minutes Lorazepam/ diazepam by slow IV--> large vein/ midazolam oromucosal solution buccally/ diazepam rectally

Question 186

Tx for methaemoglobinaemia?

Answer 186

Methylthioninium chloride if conc 30% or higher/ sx of tissue hypoxia present despite oxygen therapy

Question 187

Repeated doses of activated charcoal by mouth given with what overdosage? If vomiting after dosing given what? Other techniques used in hospital?

Answer 187

Carbamazepine, dapsone, phenobarbital, quinine, theophylline Antiemetic Haemodialysis for ethylene glycol, lithium, methanol, phenobarbital, salicylates, and sodium valproate/ alkalinisation of the urine for salicylates

Question 188

What are the main features of salicylate poisoning? Level for less severe? Tx for ingesting within 1 hour of >125mg/kg aspirin? What should be replaced and what may be given to enhance urinary salicylate excretion? Tx for severe poisoning>700mg/ litre/ severe metabolic acidosis?

Answer 188

Hyperventilation, tinnitus, deafness, vasodilatation and sweating- severe= coma, but uncommon Plasma- salicylate conc<500mg/ litre unless evidence of met acidosis Activated charcoal, fluid losses- IV sodium bicarbonate (ensuring K+ conc in range) Haemodialysis

Question 189

Sx of opioid poisoning? Antidote if coma/ bradypnoea? If repeated administration needed, route? What have long durations of action and need long monitoring periods? Norpropoxyphene(metabolite of dextropropoxyphene) may require what due to cardiotoxic effects?

Answer 189

Coma, resp depression & pinpoint pupils Naloxone hydrochloride Continuous IV infusion Dextropropoxyphene and methadone Sodium bicarbonate or magnesium sulfate/ both

Question 190

Early sign of paracetamol poisoning? What indicates hepatic necrosis? When is liver damage maximal? When does NAC prevent/ reduce liver damage severity if given up to what time period? Most effective within how long? Weight to use in obese patients >110kg?

Answer 190

N&V- usually settle within 24 hours Recurrence of N&V after 2-3 days, right subcostal pain and tenderness 3-4 days 24 hours- 8 hours 110kg

Question 191

When should activated charcoal be considered for paracetamol poisoning? Patients at risk of liver damage and requiring acetylcysteine can be identified how? How to interpret NAC graph? What if the time of ingestion is unknown?

Answer 191

Within 1 hour of ingesting in excess of 150mg/kg Single measurement of the plasma-paracetamol conc provided not <4 hours(above 4 hours can check paracetamol level) On/ above the tx line= commence NAC Tx as a staggered dose- tx with NAC without delay

Question 192

How does the 21-hour regimen for NAC work?

Answer 192

3 consecutive IV infusions over 21 hours- added to glucose 5% or NaCl 0.9% IV infusion

Question 193

How does poisoning with tricyclic and related antidepressants present? What is given to arrest arrhythmias?

Answer 193

Dry mouth, coma of varying degree, hypotension, hypothermia, hyperreflexia, extensor plantar responses, convulsions, respiratory failure, cardiac conduction defects and arrhythmias, dilated pupils, urinary retention Met acidosis may complicate severe poisoning Sodium bicarbonate

Question 194

Sx in SSRI poisoning? What given within 1 hour can reduce absorption of the drug? Antimalarial poisoning?

Answer 194

N&V, agitation, tremor, nystagmus, drowsiness, sinus tachycardia, convulsions Activated charcoal Arrhythmias and convulsions

Question 195

Sx of phenothiazine poisoning? Abolishing dystonic reactions? 2nd generation antipsychotics? Tx?

Answer 195

Hypotension, hypothermia, sinus tachycardia, dystonic reactions, convulsions Procyclidine hydrochloride or diazepam Drowsiness, convulsions, EP sx, hypotension, ECG abnormalities Supportive, activated charcoal within 1 hour

Question 196

Benzos taken alone can cause what? What can be hazardous?

Answer 196

Drowsiness, ataxia, dysarthria, nystagmus and occasionally resp depression & coma Flumazenil- particularly in mixed overdoses with tricyclics/ benzo- dependent patients

Question 197

Beta-blocker overdose may cause what? Tx? Tx for symptomatic bradycardia? Bronchospasm?

Answer 197

Cardiac effects e.g. bradycardia, hypotension, syncope, conduction abnormalities, HF, ventricular tachyarrhythmias secondary to QT interval prolongation/ QRS duration Also CNS effects Fluid resus- vasopressors, inotropes, IV glucagon in severe hypotension, HF/ cardiogenic shock IV atropine sulfate; dobutamine/ isoprenaline- w/ hypotension, nebulised bronchodilators and corticosteroids

Question 198

If BM is persistently above 10mmol/L before lunch/ evening meal do what? Before bed/ breakfast? Low BM(e.g. <4mmol/L)?

Answer 198

Increase breakfast dose Increase evening meal dose(typically 10%) Reduce the breakfast dose Reduce the evening meal dose(typically by 10%) (Dose BEFORE will have impact)

Question 199

Features of CCB poisoning? Tx? Sx of iron salts poisoning? Tx?

Answer 199

Nausea, vomiting, dizziness, agitation, confusion, and coma in severe poisoning- met acidosis and hyperglycaemia may occur Activated charcoal within 1 hour, calcium chloride or calcium gluconate by injection, atropine sulfate for symptomatic bradycardia N&V, abdominal pain, diarrhoea, haematemesis & rectal bleeding Desferrioxamine mesilate- chelates iron

Question 200

Sx of lithium poisoning? Therapeutic and toxic ranges? Tx?

Answer 200

Apathy, restlessness, vomiting, diarrhoea, ataxia, weakness, dysarthria, muscle twitching, tremor 0.4-1mmol/ litre, in excess of 2 mmol/ litre Neurological sx/ renal failure- haemodialysis may be needed, increase urine output, supportive, gastric lavage may be considered

Question 201

Sx of stimulant drug poisoning? Early stages controlled by what?

Answer 201

Wakefulness, excessive activity, paranoia, hallucinations, HTN followed by exhaustion, convulsions, hyperthermia and coma Diazepam or lorazepam

Question 202

Sx of cocaine poisoning? Tx? Ecstasy?

Answer 202

Agitation, dilated pupils, tachycardia, HTN, hallucinations, hyperthermia, hypertonia, hyperreflexia IV diazepam for agitation and cooling measures for hyperthermia Delirium, coma, convulsions, ventricular arrhythmias, hyperthermia, rhabdomyolysis

Question 203

Tx for cyanide poisoning? Suspicion of severe poisoning? If this isn't available?

Answer 203

Oxygen Dicobalt edetate, sodium nitrite followed by sodium thiosulfate Hydroxoxobalamin- smoke inhalation victims = sx of cyanide poisoning

Question 204

Tx for ethylene glycol and methanol poisoning? Features and tx of organophosphate poisoning?

Answer 204

Fomepizole Anxiety, restlessness, dizziness, headache, miosis, nausea, hypersalivation, vomiting, abdominal colic, diarrhoea, bradycardia, sweating, muscle weakness and fasciculation Atropine sulfate, pralidoxime chloride= adjunct

Question 205

What are the 7 deadly sins of prescribing?

Answer 205

1) Not knowing your drug 2) Not knowing your patient 3) Failing to take an accurate drug history 4) Writing an illegible prescription 5) Using inappropriate abbreviations, decimals and leadings zeros 6) Failing to calculate and check drug doses accurately 7) Failing to give clear instructions and using inappropriate verbal orders

Question 206

What is prophylactic heparin contraindicated in? Ho do enzyme inhibitors like erythromycin affect warfarin? Drugs that increase bleeding e.g. aspirin, heparin and warfarin should not be given to who?

Answer 206

Acute ischaemic stroke It increases it's effect and thus the PTT & INR Those who are bleeding, suspected of bleeding or at risk of bleeding e.g. those with a prolonged PTT due to liver disease

Question 207

Mnemonic for remembering the SEs of steroids? Common cautions and CIs for NSAIDs?

Answer 207

STEROIDS: stomach ulcers, thin skin, oedema, right and left heart failure, osteoporosis, infection- including Candida, diabetes, Cushing's syndrome NSAID: no urine i.e. renal failure, systolic dysfunction i.e. HF, asthma, indigestion- any cause, dyscrasia- clotting abnormality

Question 208

3 categories of SEs for antihypertensives?

Answer 208

a) Hypotension- from all groups b) 1. Bradycardia- Beta-blockers and some CCBs 2. Electrolyte disturbance with ACE-i & diuretics c) 1. ACE-i--> dry cough 2. Beta-blockers--> wheeze in asthmatics; worsening of acute HF- improves chronic HF 3. CCBs--> peripheral oedema and flushing 4. Diuretics--> renal failure, Loop diuretics--> gout & K+- sparing--> gynaecomastia

Question 209

What is rapid tranquilisation? First think what?

Answer 209

Use of medication by parenteral route if de-escalation & oral medication not possible/ urgent sedation necessary for safety because of disturbed/ dangerous behaviour DDx- OD, HI, brain disorder, substances, hypoxia De-escalation techniques- voice, posture, kindness, low stimulus environment, empathy, physical health checks if possible including ECG, CI- resp/ CVDs, support of team and trained staff for restraint, discussion with senior staff if possible

Question 210

Medication for tranquilisation? Post-tranquilisation?

Answer 210

Revisit oral options- lorazepam 1-2mg/ haloperidol 5-10mg + promethazine 25-50mg(helps with EP SEs of haloperidol,) IM= lorazepam 1-2mg/ haloperidol 2.5-5mg + promethazine 25-50mg Documentation, physical health checks- SE= dystonia, resp depression, urinary retention, debrief with team

Question 211

When neuroleptic malignant syndrome occur? Sx? Tx?

Answer 211

1-2/52 of start of changed dose All neuroleptics and other dopaminergic meds Fever, altered mental state, muscular hypoactivity & severe(lead pipe rigidity,) increased CK, WCC & LFTs, low Fe, AN dysfunction, ileus

Question 212

When does serotonergic syndrome occur?

Answer 212

Within 24 hours- all SSRIs, other 5HT-1 & 2 meds, tramadol Fever, altered mental state, NM hyperactivity, hyperreflexia, clonus Often none, can be high CK & WCC, AN hyperactivity, shivering hyperactive bowel, dilated pupils Stop SSRI & supportive care

Question 213

Common SEs of lithium? Rare SEs? Lithium toxicity sx? Ix? Tx? Prevention?

Answer 213

Nausea, diarrhoea, dry mouth, metallic taste, thirsty, mild tremor Renal dysfunction, hypo/ hyperthyroidism, foetal abnormality if used in 1st trimester pregnancy Narrow TI, levels 0.4-1.0mEq/L: polyuria, incontinence, nausea, drowsy, confusion, blackouts, faints, blurred vision, shaking/ muscle twitches, spasms in face, tongue and neck U&E, TFT, lithium levels Supportive, haemodialysis Regular bloods, avoid dehydration, don't reduce Na suddenly, care with diuretics, SSRIs, epilepsy meds, ABx, NSAIDs

Question 214

Acute dystonic reaction related to what? Sx? Tx?

Answer 214

Antipsychotic use, arms held in dystonic posture, neck spasm to side, mouth open, dysarthria(tongue dystonia,) upward eye gaze (oculogyric crisis,) pain and distress Procyclidine 5-10mg IM

Question 215

Other SEs of antipsychotics?

Answer 215

Akathisia(mins-days)= motor restlessness + agitation- switch to 2nd generation/ reduce dose Drug induced Parkinsonism(days- months)= brady/ akinesia, rigidity- switch to 2nd gen or procyclidine Tardive dyskinesia(years)- jaw, tongue, face, choreiform/ tics, no rx Metabolic: weight gain, diabetes mellitus, hyperlipidaemia, HTN, arrhythmias, QT prolongation, stroke and venous thrombosis, liver impairment GI: hypersalivation, constipation, hyperprolactinaemia, gynaecomastia Sexual dysfunction/ glaucoma- muscarinic Neutropenia- esp clozapine(ask about bowels)

Question 216

What are the 7 deadly sins of prescribing?

Answer 216

1) Not knowing your drug 2) Not knowing your patient 3) Failing to take an accurate drug history 4) Writing an illegible prescription 5) Using inappropriate abbreviations, decimals and leadings zeros 6) Failing to calculate and check drug doses accurately 7) Failing to give clear instructions and using inappropriate verbal orders

Question 217

Patient who is NBM should still receive what? Give all patients 0.9% saline unless what?

Answer 217

Their oral medication They're hypernatraemic or hypoglycaemic--> 5% dextrose Ascitic--> human-albumin solution (HAS) Shocked with systolic BP<90 mmHg--> gelofusine(colloid) Shocked from bleeding--> blood transfusion, colloid first if not available

Question 218

If tachycardic/ hypotensive? If only oliguric? For maintenance, electrolytes met with what? Adding KCl to either is guided by what? Required per day? IV K+ less than what rate?

Answer 218

500ml bolus (250ml if HF,) then reassess patient & not due to urinary obstruction- 1L over 2-4 hours then reassess 1L 0.9% saline and 2 litres of 5% dextrose (1 SALTY + 2 SWEET) U&Es 40mmol, so 20mmol KCl in x2 bags 10mmol/ hour

Question 219

If giving 3 litres a day, give what? 2 litres? Check what?

Answer 219

8-hourly bags 12 hourly bags U&E, not fluid overloaded- JVP, peripheral/ pulmonary oedema, bladder isn't palpable- due to urinary obstruction

Question 220

Who shouldn't be prescribed compression stockings? Cyclizine is a good 1st-line anti-emetic except in who- what is safer? Avoid metoclopramide in who?

Answer 220

Patients with PAD Cardiac cases- can worsen fluid retention- metoclopramide Patients with Parkinson's due to risk of exacerbating sx, young women due to dyskinesia i.e. unwanted movements especially acute dystonia

Question 221

Prescribe what 'as required' when a patient has no pain? Prescribe what regularly for mild pain? 'As required'? Prescribe what regularly for severe pain? 'As required'? Suitable replacement?

Answer 221

Paracetamol 1g up to 6-hourly oral Paracetamol 1g 6-hourly oral/ codeine 30mg up to 6-hourly oral Co-codamol 30/500- 2 tablets 6-hourly oral/ morphine sulfate 10mg up to 6-hourly oral Tramadol

Question 222

What analgesic may be introduced at any point regularly or 'as required'? Tx for neuropathic pain and painful diabetic neuropathy?

Answer 222

NSAID- e.g. ibuprofen 400mg 8-hourly Amitriptyline- 10mg oral nightly/ pregabalin- 75mg oral 12-hourly Duloxetine- 60mg oral daily

Question 223

What drugs commonly cause hyperkalaemia and hypokalaemia?

Answer 223

HYPER= ACE-i and aldosterone antagonists e.g. HYPO= Loop and thiazide- like diuretics

Question 224

What is Novomix? How are all insulins given except for sliding scales using short-acting insulin e.g. Actrapid or Novorapid? What should Verapamil not be given with?

Answer 224

A mix of a short-term and medium acting insulin S/C injection/ IV infusion Beta-blockers

Question 225

The 'D's causing hypernatraemia? Causes of microcytic, normocytic and macrocytic anaemia?

Answer 225

Drugs- effervescent tablet preps or IV preparations with a high Na+ content, diabetes insipidus, drips- too much IV saline Iron deficiency, sideroblastic anaemia, thalassaemia Anaemia of chronic disease, acute blood loss, haemolytic anaemia, renal failure B12/ folate deficiency, excess alcohol, liver disease Hypothyroidism Haem disorders beginning with M- myeloma, myeloproliferative, myelodysplastic

Question 226

Mnemonics for causing hypokalaemia and hyperkalaemia?

Answer 226

DIRE= hypo: drugs (Loop and thiazide diuretics,) inadequate intake or intestinal loss, renal tubular acidosis endocrine- Cushing's and Conn's syndromes DREAD= hyper: drugs (K+-sparing diuretics & ACE-i,) renal failure, endocrine- Addison's disease, artefact- very common due to clotted sample, DKA

Question 227

Mnemonics for causing hypokalaemia and hyperkalaemia?

Answer 227

DIRE= hypo: drugs (Loop and thiazide diuretics,) inadequate intake or intestinal loss, renal tubular acidosis endocrine- Cushing's and Conn's syndromes DREAD= hyper: drugs (K+-sparing diuretics & ACE-i,) renal failure, endocrine- Addison's disease, artefact- very common due to clotted sample, DKA

Question 228

Mnemonics for causing hypokalaemia and hyperkalaemia?

Answer 228

DIRE= hypo: drugs (Loop and thiazide diuretics,) inadequate intake or intestinal loss, renal tubular acidosis endocrine- Cushing's and Conn's syndromes DREAD= hyper: drugs (K+-sparing diuretics & ACE-i,) renal failure, endocrine- Addison's disease, artefact- very common due to clotted sample, DKA

Question 229

Mnemonics for causing hypokalaemia and hyperkalaemia?

Answer 229

DIRE= hypo: drugs (Loop and thiazide diuretics,) inadequate intake or intestinal loss, renal tubular acidosis endocrine- Cushing's and Conn's syndromes DREAD= hyper: drugs (K+-sparing diuretics & ACE-i,) renal failure, endocrine- Addison's disease, artefact- very common due to clotted sample, DKA

Question 230

Causes of neutrophilia, neutropenia and lymphocytosis?

Answer 230

Bacterial infection, tissue damage, steroids Viral infection, chemo/ radiotherapy, clozapine, carbimazole Viral infection, lymphoma, CLL

Question 231

Causes of thrombocytopenia and thrombocytosis?

Answer 231

Infection- usually viral, drugs- esp penicilliamine e.g. in RA tx, myelodysplasia, myelofibrosis, myeloma, heparin, hypersplenism, DIC, ITP, HUS, TTP Reactive: bleeding, tissue damage, post-splenectomy, myeloproliferative disorders

Question 232

Hypovolaemic, euvolaemic and hypervalaemic causes of hyponatraemia?

Answer 232

Fluid loss, Addison's disease, diuretics SIADH, psychogenic polydysplasia, hypothyroidism HF, renal failure, liver failure--> hypoalbuminaemia, nutritional failure--> hypoalbuminaemia, thyroid failure- hypothyroidism(can be euvolaemic too)

Question 233

Pre-renal, intrinsic renal and post-renal causes of AKI?

Answer 233

Urea rise >> creatinine rise- dehydration, sepsis, blood loss, renal artery stenosis Urea rise<< creatinine rise= INTRINSIC- ischaemia, nephrotoxic ABx(esp gentamicin, vancomycin and tetracyclines)/ tablets- ACE-i, NSAIDs, radiological contrast, injury- rhabdomyolysis, negatively birefringent crystals(gout,) syndromes- glomerulonephridites, inflammation- vasculitis, cholesterol emboli Urea rise<< creatinine rise- in lumen= stone sloughed papilla, in wall= tumour(renal cell, transitional cell,) fibrosis, external pressure- BPH, prostate cancer, lymphadenopathy, aneurysm

Question 234

How to differentiate severe prerenal AKI from intrisic and obstructive AKI?

Answer 234

Multiple urea by 10- if this exceeds the creatinine--> prerenal aetiology

Question 235

ALKPHOS mnemonic to remember causes of raised ALP?

Answer 235

Any fracture, liver damage, K for cancer, Paget's disease of bone and pregnancy, hyperparathyroidism, osteomalacia and surgery

Question 236

Prehepatic causes of raised bilirubin? Intrahepatic causes of raised bilirubin and raised AST/ ALT? Posthepatic causes of raised bilirubin and ALP?

Answer 236

Haemolysis, Gilbert's and Crigler- Najjar syndromes Fatty liver, hepatitis, cirrhosis, malignancy- primary/ secondary, metabolic- Wilson's disease/ haemochromatosis, HF In lumen: stone(gallstone,) drugs causing cholestasis- flucloxacillin/co-amoxiclav/ nitrofurantoin/ steroids/ sulphonylureas, in wall: tumour, PBC, sclerosing cholangitis, extrinsic pressure- pancreatic/ gastric cancer, lymph node

Question 237

Liver cirrhosis may be due to what?

Answer 237

Alcohol, viruses- hep A-E, CMV and EBV, drugs- paracetamol OD, statins, rifampicin, AI- PBC, PSC and autoimmune hepatitis

Question 238

PRIM mnemonic for CXRs?

Answer 238

Projection- normally PA Rotation- if distance between spinous processes and clavicles equal then no rotation Inspiration- if seventh anterior down-sloping rib transects the diaphragm then adequate Markings- if additional e.g. 'red marks' then the radiographer has spotted an abnormality

Question 239

Pleural effusion on CXR? Pneumonia? Oedema? Fibrosis?

Answer 239

Unilateral + solid Unilateral + fluffy Bilateral and fluffy Bilateral and honeycomb

Question 240

Trachea in lobar collapse? Pneumothorax? Widened mediastinum? Consider with bones?

Answer 240

Towards affected side, away from affected side Right upper lobe collapse with tracheal deviation/ aortic dissection TD Rib fractures or lytic lesions- usually in mets

Question 241

Difficult areas on CXRs?

Answer 241

Sharp CP angles?- not suggest effusion Air under right hemidiaphragm- bowel perf/ recent surgery, under left side= gastric air bubble which is normal Triangle behind heart (sail sign,)- left lower lobe collapse Clear apices- consider TB/ apical tumour

Question 242

What to do if gentamicin serum level is high(without toxicity signs)? Signs of digoxin toxicity? Lithium? Phenytoin? Gentamicin? Vancomycin?

Answer 242

Reduce frequency by 12h rather than reducing the dose from every 24h--> 36h Confusion, nausea, visual halos and arrhythmias Early= tremor, intermediate= tiredness, late= arrhythmias, seizures, coma, renal failure and diabetes insipidus Gum hypertrophy, ataxia, nystagmus, peripheral neuropathy and teratogenicity Ototoxicity and nephrotoxicity, "

Question 243

How should gentamicin be monitored? If the post-dose(peak) is high, what to do? What if the pre-dose 'trough' is too high? Normal peak and trough levels in IE and everything else?

Answer 243

Blood samples should be taken approximately 1 hour after intramuscular or intravenous administration (‘peak’ concentration) and also just before the next dose (‘trough’ concentration) The interval between doses must been increased 3-5, 5-10 <1, <2

Question 244

General gentamicin dose in normal and severe renal failure/ endocarditis patients? Nomograms to use for gentamicin? Plots what against what? How to interpret?

Answer 244

5-7mg/kg OD CrCl<20/ml/min or endocarditis= 1mg/ kg 12- hourly(renal failure,) or 8-hourly (in endocarditis) Hartford if 7mg/ kg dose, Urban and Craig if 5mg/ kg dose Blood level= y-axis and time between last infusion and taking the blood= x- axis Within 24h area= continue, in 36h area--> 36-hourly dosing, within 48h--> 48-hourly dosing Above 48h= repeat gentamicin level and re-dose when conc< 1mg/ L

Question 245

How does NAC work? Who do you use PTT in instead of INR? Target INR for those on warfarin, unless recurrent thromboembolism whilst on it/ metal replacement heart valves where it's what? Tx if there's a major bleed--> hypotension or bleeding into a confined space i.e. brain/ eye?

Answer 245

Replenishes glutathione to reduce levels of NAPQI Those with liver disease/ DIC 2.5/ 3.5 Stop warfarin, give 5-10mg IV Vitamin K, give prothrombin complex (e.g. Beriplex)

Question 246

Tx if INR<6? Between 6-8? >8?

Answer 246

Reduce warfarin dose Omit warfarin for 2 days then reduce dose Omit warfarin and give 1-5mg oral vitamin K

Question 247

Most common tx plan for neutropenic sepsis?

Answer 247

Piperacillin with tazobactam and gentamicin

Question 248

Causes of SIADH mnemonic?

Answer 248

SIADH: small cell lung tumours, infection, abscess, drugs- esp carbamazepine and antipsychotics & head injury

Question 249

When are UTI considered recurrent? What isn't usually tx with antibacterials?

Answer 249

At least 2 episodes within 6 months or 3 or more episodes within 12 months Asymptomatic bacteriuria

Question 250

Avoid what in patients with heart failure with a reduce ejection fraction? HF & angina tx with what? Tx for SOB and breathlessness? Thiazide diuretics when?

Answer 250

Verapamil and diltiazem, nifedipine Amlodipine Furosemide/ bumetanide Mild fluid retention and eGFR> 30mL/ minute/ 1.73 metres2

Question 251

1st line tx in HF? If ACE-i not tolerated? If sx worsen/ persist? If ACE-i and ARB not tolerated? Add-on in worsening/ severe HF despite optimal tx?

Answer 251

ACE-i e.g. perindopril, ramipril, captopril, lisinopril etc and Beta-blocker licensed for HF ARB e.g. candesartan/ losartan/ valsartan Spiro unless CI due to hyperkalaemia or renal impairment Hydralazine hydrochloride w/ a nitrate Digoxin

Question 252

How should ACE-i, ARBs and mineralocorticoid receptor antagonists be monitored for tx of HF?

Answer 252

Serum K+ and Na+, renal function, and BP checked prior to starting tx, 1-2 weeks after starting tx, and each dose increment Once target/ max tolerated dose reached--> monitor monthly for 3 months and then at least every 6 months

Question 253

General tx for STEMIs and NSTEMIs?

Answer 253

ABC and O2(15L) by non-rebreather mask unless COPD, hx/ OE, aspirin 300mg oral, morphine 5-10mg IV with metoclopramide 10mg IV, GTN spray/ tablet, Beta- blocker e.g. atenolol 5mg oral- unless LVF/ asthma, transfer CCU STEMI= primary PCI(preferred or thrombolysis) NSTEMI= clopidogrel 300mg oral and LMWH herpain e.g. enoxaparin 1mg/ kg BD SC

Question 254

General dose of SC dalteparin for DVT and PE? Antidote for LMWHs? Who is it safe in? What should be measured just before treatment? What else?

Answer 254

200 units/ kg daily- usually 5 days combined tx needed Protamine sulfate Pregnant women Platelet counts- regular monitoring if given for longer than 4 days Plasma potassium if at risk of hyperkalaemia- particularly if treatment for longer than 7 days

Question 255

General tx for acute LVF?

Answer 255

ABC and O2 (15L) by non-rebreather mask (unless COPD,) hx/ O/E/ inv, sit patient up, morphine 5-1mg IV with metoclopramide 10mg IV, GTN spray/ tablet, furosemide 40-80mg IV, inadequate response- isosorbide dinitrate infusion +/- CPAP, transfer CCU

Question 256

Initial actions for adult tachycardias with a pulse? If adverse features i.e. shock, syncope, myocardial ischaemia, HF?

Answer 256

ABCDE, O2 if appropriate, IV access, ECG, BP, SpO2, 12-lead ECG, tx reversible causes e.g. electrolytes Synchronised DC shock- up to 3 attempts--> amiodarone 300mg IV over 10-20 minutes and repeat shock; followed by; amiodarone 900mg over 24h

Question 257

What if someone with tachycardia is stable with a broad QRS complex(>0.12s) and irregular pulse? Regular pulse?

Answer 257

Seek expert help: possibilities= AF w/ BBB, pre-excited AF- consider amiodarone, polymorphic VT e.g. torsade de pointes- give magnesium 2g over 10 minutes If VT - amiodarone 300mg IV over 20-60 min, then 900mg over 24h SVT w/ BBB= adenosine as for regular narrow complex complex tachycardia

Question 258

What if someone with tachycardia is stable with a narrow QRS complex(<0.12s) and irregular pulse? Regular pulse? If sinus rhythm is restored? Isn't restored?

Answer 258

Irregular narrow complex tachycardia- probable AF, control rate w/ Beta-blocker or diltiazem, consider digoxin or amiodarone if evidence of HF Use vagal manoeuvres, adenosine 6mg rapid IV bolus; unsuccessful--> 12mg; further 12mg, monitor ECG continuously Probable re-entry paroxysmal SVT: 12-lead ECG in sinus rhythm, recurs- give adenosine again, consider choice of anti-arrhythmic prophylaxis Possible atrial flutter- control rate e.g. Beta- blocker

Question 259

Anaphylaxis tx including anaphylactic transfusion reaction?

Answer 259

ABC and O2(15L) non-rebreather mask(unless COPD,) remove cause ASAP, adrenaline 500mcg of 1:1000IM, chlorphenamine 10mg IV, hydrocortisone 200mg IV, asthma tx if wheeze, amend drug chart allergies box

Question 260

Who to offer rhythm control for AF to? Rate control?

Answer 260

If young/ symptomatic AF/ 1st episode/ due to precipitant- sepsis/ electrolyte disturbance Everyone else w/ HR> 90 bpm

Question 261

If a patient with AF is unstable, tx? When to offer rate control? Options for rate control?

Answer 261

Immediate DC cardioversion Whose AF has a reversible cause, HF thought to be primarily caused by AF, with new-onset AF, rhythm control would be more suitable Beta-blocker e.g. propanolol 10mg 6-hourly/ rate-limiting CCB e.g. Diltiazem 120mg/ verapamil- AVOID W/ BETA-BLOCKERS Digoxin monotherapy with non-paroxysmal AF only if they're sedentary/ hypotensive/ co-existent HF(avoid in younger patients)/ CI to Beta-blockers and CCBs- load then start 62.5-125mcg daily

Question 262

2 methods for rhythm control in AF? If the AF is acute<48 hours? If it's >48 hours, then must be anticoagulated for at least how long before DC cardioverted?

Answer 262

Electrical cardioversion/ pharmacological cardioversion i.e. amiodarone 5mg/ kg IV over 20-120 minutes, anticoagulation if>48 hours onset DC cardioverted with sedation At least 3 weeks/ can have a transoesophageal ECHO to rule out a thrombus in the left atrial appendage before cardioversion

Question 263

When is flecainide used in AF? Amiodarone? Sotalol? Patients should be risk stratified using what? Interpretation? Generally?

Answer 263

Young patients who have structurally normal hearts Older, sedentary patients Don't meet the demographics for flecainide or amiodarone CHADS2VASc Males who score 1 or more/ females who score 2 or more should be anticoagulated 0= consider aspirin 75mg daily, 1= aspirin/ warfarin aiming for INR 2.5, score 2 or more= warfarin aiming for INR 2.5

Question 264

Anticoagulation options for AF? Only oral anticoagulant licenced for valvular AF?

Answer 264

Edoxaban, apixaban, rivaroxaban & dabigatran- don't need monitoring, less bleeding risks than warfarin Warfarin- needs LMWH cover for 5 days when initiating tx, INR monitoring, effect lasts days, rare option for those who cannot tolerate oral tx, daily tx dose injections

Question 265

Who is atrial ablation an option for in AF?

Answer 265

For some patients who have uncontrolled sx and have an identifiable locus in their left atrium

Question 266

Tx for acute asthma? Acute exacerbation of COPD?

Answer 266

ABCDE- ensure patent airway, 100% O2 by non-rebreather mask, salbutamol 5mg NEB, 100mg hydrocortisone IV/ pred 40-50mg oral if moderate, ipratropium 500mcg NEB, IV theophylline/ aminophylline/ magnesium sulfate only if life-threatening Same asthma but add ABx if infective exacerbations- high-flow O2 with care due to T2RF (not peri-arrest= 28% oxygen is a safe starter with an ABG 30 minutes later to assess the effect)

Question 267

Tx of chronic asthma?

Answer 267

SABA, add ICS e.g. beclametasone, add LABA e.g. salmeterol- no benefit= stop this and increased ICS dose; if benefit, but inadequate control= increase ICS dose, trial oral leukotriene receptor antagonist, high-dose steroid, oral B2- agonist

Question 268

Tx for pneumonia/ PE?

Answer 268

ABC, high-flow oxygen, antibiotics e.g. amoxicillin/ co-amoxiclav, paracetamol, IV fluids High-flow oxygen, morphine 5-10mg IV, metoclopramide 10mg IV, LMWH e.g. tinzaparin 175 units/ kg SC daily, low BP= IV gelofusine--> NAD--> thrombolysis

Question 269

8 Cs of treating GI bleeding? If BP normal/ high? If BP low? Once cross-matched? If PT/ aPTT >1.5 normal range?

Answer 269

O2(15L via non-rebreather mask unless COPD,) x2 large bore cannulae, cross-match 6 units blood, correct clotting abnormalities, endoscopy, stop NSAIDs/ aspirin/ warfarin/ heparin, call surgeons if severe 0.9% saline/ colloid- gelofusine/ give blood Fresh frozen plasma unless due to warfarin- give prothrombin complex, if platelets<50 x 10^9--> platelet transfusion

Question 270

Empiric tx for suspected acute bacterial meningitis? Other tx?

Answer 270

2g IV ceftriaxone x2 daily + IV amoxicillin in young/ old patients to cover listeria and IV aciclovir if viral encephalitis suspected 1.2g benzylpenicillin before urgent transfer to hospital/ 1g IV cefotaxime(pre-LP if having CT head or prolonged LP) if allergic to penicillin/ chloramphenicol injection 1g if reaction--> penicillin/ cephalosporins IV Dex unless immunocompromised, LP+/- CT head

Question 271

Tx of status epilepticus?

Answer 271

Community= PR diazepam 10mg/ buccal midazolam 10mg Early status(0-30 minutes= IV Lorazepam 0.1mg/kg(usually 4mg bolus) Premonitory stage(0-10 minutes)= diazepam 10-20mg rectally repeated once 15 minutes later/ 10mg midazolam buccally Established= phenytoin infusion 15-18mg/kg at a rate of 50mg/ minute, inform anaesthetist, intubate then propofol, thiopental sodium Established= valproate and Leviteracetam can be used instead of phenytoin

Question 272

Tx of ischaemic stroke? CI to thrombolysis?

Answer 272

Thrombolysis w/ alteplase within 4.5 hours of symptom onset & <80 y/o Recent head trauma, GI/ IC haemorrhage, recent surgery, acceptable BP, platelet count and INR Mechanical thrombectomy with anterior circulation strokes within 6 hours of sx onset & posterior circulation strokes up to 12 hours after onset 300mg aspirin within 24 hours

Question 273

Long-term tx for ischaemic strokes?

Answer 273

75mg clopidogrel OD for log-term antiplatelet therapy/ dipyridamole w/ aspirin, HTN tx 2 weeks post stroke(not Beta-blockers,) secondary to AF= warfarin/ DOAC 2 weeks post-stroke, 20-80mg atorvastatin once nightly 48 hours after sx onset, screen for diabetes, ipsilateral carotid artery stenosis>50%--> carotid endarterectomy

Question 274

What is hypoglycaemia classed as? Tx mild hypoglycaemia(still conscious)? Severe? Unconscious/ having seizures/ aggressive? What if an insulin injection is due?

Answer 274

Someone with diabetes blood glucose conc<4mmol/ litre 15-20g fast-acting carb, avoid chocolate, some slower-acting carbs afterwards 200ml 10% dextrose IV, 1mg glucagon IM if no IV access- won't work if due to alcohol- give thiamine supplementation Stop any IV insulin & tx initially with glucagon/ 10% IV glucose infusion if no response/ 20% It should not be omitted

Question 275

What is needed for a DKA diagnosis? Tx if patient is alert? If they're vomiting, confused or significantly dehydrated? Shocked/ comatosed?

Answer 275

Ketonaemia 3mmol/L and over, blood glucose>11 mmol/L, bicarbonate below 15mmol/L/ venous pH< 7.3 SC insulin injection IV fluids 10mls/ kg 0.9% NaCl, insulin infusion 0.1 units/kg/hour 1 hour after starting IV fluids- if evidence of shock initial bolus should be 20 mls/ kg ABCDE

Question 276

Targets for type 1 diabetics, on waking, before meals at other times of day, at least 90 minutes after eating, when driving?

Answer 276

48mmol/L or lower 5-7mmol/ litre 4-7mmol/ litre 5-9 mmol/ litres At least 5 mmol/ litre

Question 277

1st line choice of insulin regimen for type 1 diabetics? What do multiple daily injection basal- bolus insulin regimens involve? Mixed biphasic regimens? Other option?

Answer 277

Multiple daily injection basal-bolus insulin regimens One/ more separate daily injections of intermediate-acting/ long-acting insulin analogue as the basal insulin alongside multiple bolus injections of short-acting insulin before meals 1/2/3 insulin injections per day of short-acting mixed with intermediate- acting insulin Continuous SC insulin infusion

Question 278

What should be offered as the long-acting basal insulin therapy? What if this isn't tolerated? If there's concerns about nocturnal hypoglycaemia? If help is needed with injection administration? Alternative regimen?

Answer 278

Twice- daily insulin detemir Once-daily insulin glargine Insulin degludec Once-daily insulin degludec/ glargine 300 units/ ml Twice-daily mixed insulin regimen

Question 279

What isn't recommended in newly diagnosed T1DM? 3 examples of short-acting insulins? 3 types of insulin the UK? Onset of action, peak action, duration of action?

Answer 279

Non-basal- bolus insulin regimens e.g. twice- daily mixed, basal-only, or bolus- only Insulin aspart, glulisine and lispro Human insulin, human insulin analogues, animal insulin 30-60 minutes(rapid-acting= within 15 minutes) 1-4 hours Up to 9 hours(2-5 hours for rapid-acting)

Question 280

Onset of action, peak action, duration of action of intermediate- acting insulin e.g. isophane insulin? Examples and duration of action of long-acting insulins?

Answer 280

1-2 hours, 3-12 hours and 11-24 hours Insulin detemir, glargine, degludec- up to 36 hours, steady-state after 2-4 days

Question 281

How to diagnose hyperglycaemic HONK? Tx?

Answer 281

Hyperglycaemia usually>35 mmol/L, osmolality>340mmol/L, no ketones in the blood/ urine Same as DKA- half the rate of fluids

Question 282

Tx of AKI?

Answer 282

ABC, cannula & catheter, strict fluid monitoring, IV 500ml stat, then 1 L 4 hourly, hunt for cause and comps, monitor U&Es and fluid balance

Question 283

Tx BP>150/95 or >135/85mmHg if any of what are present? Target for patients<80 y/o at clinic/ ambulatory or home measurements? >80 y/o?

Answer 283

Existing/ high risk of vascular disease- IHD/ stroke/ PVD, hypertensive organ damage <140/85mmHg <135/85mmHg Add 10mmHg to the systolic values

Question 284

Options for tx HTN if potassium level is >4.5mmol/L? Definition and tx. of malignant HTN? What is usually prefered?

Answer 284

Alpha blocker e.g. Doxacosin, Beta blocker e.g. Atenolol Systolic BP above/=180mmHg and >/=120mmHg diastolic + evidence of end-organ damage Aim for controlled drop in BP to around 160/100mmHg Usually amlodipine or nifedipine Oral medication- unless encephalopathy, HF or aortic dissection

Question 285

Tx for hypertensive encephalopathy? Aortic dissection? Pulmonary oedema? Pregnancy-induced? Phaeochromocytoma?

Answer 285

IV Labetalol/ IV infusion sodium nitroprusside IV labetalol/ sodium nitroprusside- target 110-120mmHg systolic IV infusion GTN/ sodium nitroprusside- Beta-blocker not recommended Pregnancy-induced= IV magnesium sulfate w/ IV labetalol/ hydralazine/ methyldopa IV phentolamine/ phenoxybenzamine(lpha blockers) before beta blockade

Question 286

1st line tx of stable angina?

Answer 286

GTN spray as required for symptomatic relief when required Secondary prevention: aspirin, statin and CV RF modification One anti-anginal drug dependent on CIs: 1) Beta-blocker e.g. atenolol, CI= hypotension, bradycardia, asthma & HF 2) CCB e.g. amlodipine or diltiazem, CI= hypotension, bradycardia and peripheral oedema

Question 287

If still experiencing stable angina? If uncontrolled on x2 anti-anginal drugs?

Answer 287

Increase dose of beta-blocker/ CCB as tolerated Add second anti-anginal drug if not CI/ long-acting nitrate e.g. isosorbide mononitrate/ potassium channel activator e.g. nicorandil Revascularisation therapy i.e. PCI/ CABG

Question 288

Tx for T1DM & T2DM?

Answer 288

Aspirin 75mg daily if significant RFs/ >50 y/o w in T2DM, simvastatin 20-40mg daily if any significant CV RF/ over age of 40 in T2DM Annual review of complications- ACR for diabetic nephropathy & predictor of CVD e.g. ACR>3mg/mmol--> need for ACE-i Blod glucose- lowering therapy

Question 289

Blood glucose lowering therapy in T2DM?

Answer 289

1) HBA1C>48 mmol/mol after trial of diet and exercise= metformin 500mg with breakfast orally/ if low/ normal weight or creatinine>150 micromol/L--> sulphonylurea e.g. gliclazide 40mg with breakfast orally 2) Increase drug dose 3) If still above 48mmol/mol- add gliclazide, then gliptin (DPP-4 inhibitor) e.g. sitagliptin 4) Still too high= add insulin

Question 290

Inhaled therapies tx for COPD? Consider an ICS in who? Those with asthmatic features/ features suggesting steroid responsiveness?

Answer 290

SABA/ SAMA e.g. salbutamol/ ipratropium Then offer a LABA/ LAMA e.g. salmeterol/ tiotropium Those on a LAMA & LABA who have a severe exacerbation/ or at least x2 moderate exacerbations within a year(triple therapy)- review ICS annually ICS trial for 3 months if impacting QOL, sx improved= continue triple therapy & review annually No improvement= step back down to a LAMA & LABA Consider LABA & ICS- discontinue SAMA tx if a LAMA is given

Question 291

Add- on tx to bronchodilator therapy in patients with severe COPD & chronic bronchitis? Prophylaxis of exacerbations in non-smokers? Tx for exacerbation? When should aminophylline be used?

Answer 291

Roflumilast Azithromycin(all other tx options optimised) Prednisolone As add-on treatment when there is an inadequate response to nebulised bronchodilators

Question 292

Well's score for doing a D-dimer? What is given in the interim? Avoid apixaban/ rivaroxaban/ edoxaban/ dabigatran in who?

Answer 292

4 or less- low D-dimer excludes a PE Above--> CTPA/ V/Q scan LMWH Pregnant, CrCl< 15ml/ minute

Question 293

Use enoxaparin when tx a DVT with what? How long should provoked PEs be anticoagulated for? Unprovoked? Recurrence of VTE in a patient already on warfarin requires what INR?

Answer 293

Obesity, cancer, recurrent VTE/ proximal thrombosis, pregnancy 3 months 6 months An increase to 3-4

Question 294

Txs for Parkinson's? Generalised tonic-clonic, absence, myoclonic or tonic seizures?

Answer 294

Co-beneldopa or co-careldopa Dopamine agonist e.g. ropinirole or MAO-i e.g. rasagiline Sodium valproate/ " or ethosuximide/ sodium valproate/ sodium valproate/ carbamazepine or lamotrigine

Question 295

Common SEs of lamotrigine? Carbamazepine? Phenytoin? Sodium valproate?

Answer 295

Rash, rarely SJS Rash, dysarthria, ataxia, nystagmus, hyponatraemia Ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity Tremor, teratogenicity, tubby (weight gain)

Question 296

Drugs with antimuscarinic effects? Mild-to-moderate Alzheimer's tx? Alternative for moderate?

Answer 296

Amitriptyline hydrochloride, paroxetine, antihistamines, antipsychotics, urinary antispasmodics Donepezil/ galantamine/ rivastigmine Memantine (NMDA antagonist)

Question 297

Dementia with Lewy bodies tx?

Answer 297

Donepezil or rivastigmine/ galantamine if not tolerated- also in severe/ memantine if ACh inhibitors= CI or not tolerated

Question 298

Offer what ASAP for a STEMI?

Answer 298

300mg aspirin

Question 299

Tx for mild flare of Crohn's disease? Severe flare? What can be added to induce remission. if there are 2 or more exacerbations in a 12-month period? Assess what before offering azathioprine? Alternative if TPMT deficient/ intolerant to azathioprine? Severe who fail to respond?

Answer 299

30mg prednisolone daily orally Hydrocortisone 100mg 6-hourly IV Azathioprine- TPMT Methotrexate Biological agents e.g. infliximab/ adalimumab

Question 300

Indication for DMARD & biologic tx in RA? Alternative in pregnancy?

Answer 300

If the DAS28 score is >5.1 e.g. methotrexate, sulfasalazine, hydroxychloroquine and leflunomide/ infliximab- as early after symptoms occur as possible- ideally within 3 months Paracetamol with a weak opioid, low dose pred to control flares w/ joint injections (Hydroxychloroquine and/ or sulfasalazine w/ folic acid can be continued during pregnancy)

Question 301

Tx for flare of RA?

Answer 301

IM methylpred 80mg, short-term NSAIDs e.g. ibuprofen 400mg 8-hourly w/ lansoprazole, re-instate DMARDs if dose previously reduced Failure to respond--> TNF- alpha inhibitors, e.g. infliximab

Question 302

Tx for diarrhoea? Insomnia?

Answer 302

Loperamide 2mg oral up to 3-hourly/ codeine 30mg oral up to 6-hourly Zopiclone 7.5mg oral nightly in adults/ 3.75mg in the elderly

Question 303

Statins are associated with a risk of myopathy in who? What should be checked in these patients? Avoid in who?

Answer 303

Patients with a personal/ family history of muscular disorders, muscular toxicity, high alcohol intake, renal impairment, hypothyroidism and in the elderly Creatinine kinase baseline/ if no RFs alternatives e.g. LFTs- don't start if the baseline CK is >5 times the upper limit of normal Pregnancy- discontinue 3 months before attempting to conceive

Question 304

Other things to measure before starting a statin? Who shouldn't be excluded from statin therapy?

Answer 304

At least one full lipid profile including total cholesterol, HDL- cholesterol, non-HDL cholesterol & triglyceride concentrations, TSH, renal function Repeat LFTs within 3 months and at 12 months of starting tx Raised serum transaminases, but <3 times the upper limit of the reference range, discontinue in >3 times upper limit

Question 305

Check what before starting tx and after 3 months for statins in patients at a high risk of diabetes? General doses for atorvastatin?

Answer 305

HBA1c Primary prevention CV events= 20mg daily up to 80mg OD Primary hypercholesterolaemia= 10mg OD up to 80mg OD

Question 306

ADRs of gentamicin and vancomycin? Any ABx, but commonly broad-spec ABx e.g. cephalosporins or ciprofloxacin?

Answer 306

Nephrotoxicity, ototoxicity C. difficile colitis

Question 307

ADRs of antihypertensives: ACE-i, Beta-blockers, CCBs, diuretics?

Answer 307

Hypotension, electrolyte abnormalities, AKI, dry cough Bradycardia, wheeze in asthmatics, worsens acute HF- helps chronic HF Hypotension, bradycardia, peripheral oedema, flushing Hypotension, electrolyte abnormalities, AKI, subclass- dependent effects

Question 308

ADRs of anticoagulants/ antiplatelets: heparins, warfarin, aspirin?

Answer 308

Haemorrhage- especially if renal failure or <50kg, heparin-induced thrombocytopenia Haemorrhage- prescribe alongside heparin until the INR exceeds 2 Haemorrhage, peptic ulcers & gastritis, tinnitus in large doses

Question 309

ADRs of digoxin and amiodarone?

Answer 309

N&V, diarrhoea, blurred vision, confusion, drowsiness, xanthopsia- disturbed yellow/ green visual perception inc halo vision Interstitial lung disease, thyroid disease- both hypo and hyperthyroidism reported, skin greying, corneal deposits

Question 310

ADRs of lithium? Antipsychotics i.e. haloperidol & clozapine?

Answer 310

Early= tremor, intermediate= tiredness, late= arrhythmias, seizures, coma, renal failure, diabetes insipidus Dyskinesias e.g. ADR, drowsiness/ agranulocytosis- MONITOR FBC

Question 311

ADRs of corticosteroids i.e. dex, pred/ fludrocortisone?

Answer 311

STEROIDS: stomach ulcers, thin skin, edema, right & left HF, osteoporosis, infection, diabetes, Cushing's syndrome Hypertension/ sodium & water retention

Question 312

ADRs of NSAIDs? Statins?

Answer 312

NSAID: no urine- renal failure, systolic dysfunction-HF, asthma, indigestion, dyscrasia- clotting abnormality Myalgia, abdominal pain, increased ALT/ AST- can be mild, rhabdomyolysis- can be just mildly raised CK

Question 313

Drugs with a narrow therapeutic index? Ones needing careful dosage control? How long does enzyme induction and inhibition take?

Answer 313

Phenytoin, warfarin, digoxin, theophylline Antihypertensives, antidiabetic drugs Days-weeks/ hours-days

Question 314

Drugs with potent interactions with alcohol?

Answer 314

GI-bleeding= NSAIDs Lactic acidosis= metformin Increased anticoagulation caused by warfarin Sweating, flushing, N&V from metronidazole and disulfiram Hypertensive crisis caused by MAO-I Sedation caused by barbiturates e.g. phenoarbital, opioids & benzos

Question 315

What should not be co- prescribed?

Answer 315

NSAIDs & ACE-i- particularly in elderly patients with a degree of renal impairment

Question 316

What drugs should be stopped pre-operatively? Continue what drugs?

Answer 316

ACE-i, ARBs, diuretics, anticoagulants & antiplatelets, HRT & COCP- 4 weeks prior, lithium, NSAIDs(can cause blood clots/ bleeding) Cardiac/ anti-hypertensives (apart from ACE-i, ARBs & diuretics,) epilepsy & Parkinson's drugs, asthma/ COPD inhalers, PPIs, thyroid meds, antidepressants, regular steroids, immunosuppressants & cancer drugs

Question 317

Which diabetic meds do you take as normal the day before and on the day of surgery? Which do you take as normal the day before+ OD/BD, but stop lunchtime dose of TDS? Take as normal the day before, but omit the morning dose? Take as normal the day before, but omit on the day of surgery?

Answer 317

Thiazolidinediones e.g. pioglitazone, DPP-4 inhibitors e.g. gliptins and GLP-1 analogues e.g. exenatide/ liraglutide Metformin Sulphonylureas i.e. gliclazide SGLT-2 inhibitors i.e. gliflozins

Question 318

E.g. controlled drugs?

Answer 318

Morphine, oxycodone, gabapentin- strong analgesics Needs: name & address of pt, form of medication, quantity in figures & words, dose, signed & dated by prescriber

Question 319

What can taking methotrexate with NSAIDs lead to? W/ trimethoprim?

Answer 319

Low platelet count Bone marrow suppression sx Increase level of methotrexate

Question 320

Common drugs causing ototoxicity?

Answer 320

Gentamicin, bumetanide, furosemide- IV administration or if the patient has renal impairment(vestibular nerve more likely to be damaged compared to oral form,) vancomycin

Question 321

Precipitants of c.difficile? 4 Cs?

Answer 321

Co-amoxiclav, PPIs, low Mg 2+, low Na+ Clindamycin, co-amoxiclav, ciprofloxacin, cephalosporins

Question 322

You would use what PPI if they're on clopidogrel? Giving what with atorvastatin increases muscle pain, tenderness +/- dark coloured urine?

Answer 322

Lansoprazole- omeprazole= an enzyme inhibitor Macrolides i.e. erythromycin, clarithromycin, azithromycin etc

Question 323

Tx for anti-psychotic induced Parkinsonism and acute dystonia? NMS?

Answer 323

Procyclidine Bromocriptine and dantrolene

Question 324

Atypical antipsychotics e.g. quetiapine/ olanzapine can cause what? Typical antipsychotics like chlorpromazine and haloperidol?

Answer 324

Weight gain, diabetes, rise in serum lipids Acute dystonia, akathisia, tardive dyskinesia

Question 325

SEs of quinolones e.g. ciprofloxacin?

Answer 325

Increase risk of tendon rupture if on steroids, prolong QT interval/ reduces seizure threshold

Question 326

Normal blood capillary blood glucose level? Ketone level?

Answer 326

3.9- 5.6 mmol/L Lower than 0.6mmol/L

Question 327

Mnemonic for tx acute asthma?

Answer 327

OSHITME: oxygen, salbutamol 2.5-5mg nebulised, hydrocortisone 100mg IV/ pred 40mg PO, ipratropium bromide 500mcg neb every 4-6 hours, theophylline/ aminophylline, magnesium IV, escalate to senior

Question 328

Important information for starting on metformin? Sulfonylureas e.g. gliclazide? SGLT2 inhibitors e.g. dapagliflozin?

Answer 328

Lactic acidosis i.e. dyspnoea, muscle cramps, abdominal pain, hypothermia or asthenia Hypoglycaemia- higher in elderly & renal impairment S&S of DKA- even if BM is normal

Question 329

Important info for all anti-psychotics? Lithium? Clozapine? Sodium valproate?

Answer 329

Photosensitisation may occur with higher dosages- avoid direct sunlight, drowsiness may affect performance of skilled tasks- especially at start, effects of alcohol= enhanced S&S of toxicity, hypothyroidism, renal dysfunction, benign intracranial HTN, adequate fluid intake and avoid dietary changes, avoid NSAIDs Agranulocytosis Pregnancy Prevention Programme- exclude pregnancy before tx initiation, use highly effective contraception during tx

Question 330

0.3% KCl has how many mmol of K+? 0.15%? Na+ and Cl- in 0.9% NaCl? Grams of glucose in 1000ml glucose 5%? 100ml 20% glucose?

Answer 330

40mmol minimum 4h/ 20mmol minimum 2h 150mmol 50 grams/ 20 grams

Question 331

Max rate of replacing potassium? Average daily requirement of water, (K+, Na+, Cl- and glucose)? Litres needed?

Answer 331

10mmol/ hour 25-30ml/ kg/ day 1mmol/kg/day 50-100g/ day to limit starvation ketosis 2-2.5 litres(1.5l + 500-800ml in insensible losses)

Question 332

General rule of thumb for maintenance fluids?

Answer 332

One 1000ml bag of salty and a bit of potassium over 8-12 hours, one 1000ml bag of sugary (5% dextrose) a bit of potassium over 8-12 hours

Question 333

Replacement fluid when some losses e.g. diarrhoea/ vomiting, DKA?

Answer 333

1000ml NaCl 0.9% + potassium 0.3% (40mmol) over 4-6 hours

Question 334

Fluid for hypoglycaemia?

Answer 334

100ml 20% glucose over 15 minutes

Question 335

Fluid for resuscitation i.e. low BP, tachycardic, clearly unwell, sweating, sometimes still conscious?

Answer 335

500ml 0.9% over less than 15 minutes/ "fluid bolus"

Question 336

Fluid for hypokalaemia? (usually hx of diarrhoea/ vomiting or something, almost always a K+ blood test which is low)

Answer 336

1000ml 0.9% NaCl + K+ (0.3%/ 40 mmol,) over 4 hours (10 mmol/h- quickest possible)

Question 337

Fluid for hypercalcaemia? (stones, bones, abdominal groans and moans, psychiatric overtones, short QT)

Answer 337

1000ml NaCl over 4 hours

Question 338

Fluid requirements for children over 1 month under 10kg? 10-20kg? Over 20kg? Name of formula?

Answer 338

100ml/kg 50ml/kg for each 1kg body-weight over 10kg 20ml/kg for everything over 20kg 0.9% NaCl + glucose 5% 1000ml over 8-12 hours + a bit of KCl (40mmol/l) Holliday- Segar formula

Question 339

E.g. of hypovolaemic shock? Distributive shock? Cardiogenic shock? Obstructive?

Answer 339

Gastroenteritis, burns, DKA, ketoacidosis, heatstroke, haemorrhage Sepsis, anaphylaxis, neurological injury Congenital heart disease, arrhythmia Cardiac tamponade, tension pneumothorax, congenital heart disease

Question 340

If electrolyte/ blood glucose disturbance, monitor how in Paeds?

Answer 340

U&Es and plasma glucose every 24 hours

Question 341

Clinical signs of dehydration in children?

Answer 341

Appears unwell/ deteriorating, altered responsiveness, sunken eyes, tachycardia, tachypnoea, reduced skin turgor, dry mucous membranes, decrease urine output

Question 342

Clinical shock is defined by the presence of one or more of what? What is hypotension a sign of?

Answer 342

Decreased level of consciousness, pale/ mottled skin, cold extremities, pronounced tachycardia, pronounced tachypnoea, weak peripheral pulses, prolonged CRT, hypotension Decompensated shock

Question 343

Fluid of choice for neonates<28 days with no critical illness? Critical illness?

Answer 343

10% dextrose +/- additives Expert advice

Question 344

What is maintenance for term neonates calculated according to?

Answer 344

Birth--> day 1: 5-60ml/kg/day Day 2: 70-80ml/ kg/ day Day 3: 80-100ml/ kg/ day Day 4: 100-120ml/ kg/ day Day 5-28: 120-150ml/ kg/ day

Question 345

What's recommended as initial resus fluids? Standard fluid for resus in Paeds? Exceptions to this rule? What should be after the bolus has been given? If patient is still shocked/ further fluid is required?

Answer 345

Hartmann's solution 0.9% NaCl with no additives via IV/ intraosseous access bolus of 10ml/ kg over <10 minutes Neonatal period, DKA, septic shock, trauma, cardiac pathology e.g. HF Re-assess the volume status e.g. HR, RR, CRT Seek senior advice, contact the Paediatric intensive care team

Question 346

After shock/ resus has been treated, what should be calculated? For a shocked, assume what % dehydration based on body weight? Equation for fluid deficit(ml)? Total fluid requirement?

Answer 346

The fluid deficit and 24-hour replacement fluids in the same way as for any other child who was not shocked 10% 10% dehydration x weight(kg) x 10 Maintenance fluids + fluid deficit

Question 347

For patients without clinical features of shock, rehydration via what is preferred? What if this impractical/ contraindicated?

Answer 347

Via the oral or nasogastric route IV fluids may be considered with volumes based on the percentage- dehydration

Question 348

How is percentage dehydration calculated?

Answer 348

Clinically or by weight Well weight(kg)- current weight(kg)/ well weight x 100

Question 349

Clinical signs of dehydration are only detectable when the patient is what % dehydrated? S&S of dehydration, but no red flag features? If any red flags/ clinically shocked? Tx shock how?

Answer 349

2.5-5% Approximately 5% dehydrated 10% dehydration Rapidly with an initial fluid bolus before replacement fluids administered

Question 350

Fluid for hypoglycaemia in Paeds? Hypokalaemia? Hypercalcaemia? (same as adults)?

Answer 350

100ml 20% glucose over 15 minutes 1000ml 0.9% NaCl + 30% KCl (40mmol) max rate 10mmol/h over 4 hours 1000ml 0.9% NaCl over 4 hours

Question 351

Rapid correction of severe hyponatramia can lead to what? Severe hypernatramia?

Answer 351

Central pontine myelinolysis Cerebral oedema

Question 352

Consider switching to what if hypernatraemia>145mmol/L w/ evidence of dehydration? No evidence of dehydration?

Answer 352

Hypotonic fluids 0.45% NaCl Calculate fluid deficit and replace over 48 hours with 0.9% NaCl

Question 353

Tx of hyponatraemia <135mmol/L and symptomatic? Not symptomatic?

Answer 353

Seek expert help e.g. Paediatric ICU Consider restricting maintenance fluids

Question 354

With hypo/ hypernatraemia, plasma sodium should not rise or fall more than what in 24 hours? Sx associated with acute hyponatraemia?

Answer 354

12 mmol/L- monitor U&Es regularly Headache, N&V, confusion and disorientation, irritability, lethargy, reduced consciousness, convulsions, coma, apnoea

Question 355

If acute symptomatic hyponatraemia develops in term neonates, children and young people, consider what? Measure plasma sodium concentration at least how often? Do not manage what using fluid restriction alone? After sx have resolved, ensure what?

Answer 355

Bolus of 2ml/kg max 100ml of 2.7% NaCl over 10-15 minutes Further bolus 2ml/ kg over 10-15 minutes if sx still present Still present check plasma Na+ and consider 3rd bolus of 2ml/ kg Hourly Acute hyponatraemic encephalopathy That the rate of increase of plasma sodium does not exceed 12 mmol/ litre in a 24 hour-period

Question 356

Signs of hypokalaemia? ECG changes?

Answer 356

Metabolic alkalosis, arrhythmias, muscle weakness, reduced reflexes, constipation U have no Pot or no T, but a long PR and a long QT

Question 357

Sx of hypocalcaemia? Tx? Levels of calcium for hypo and hypercalcaemia?

Answer 357

CATs go numb: Convulsions, Arrhythmias, tetany, numbness, also Trousseau's sign and Chvostek's sign ECG: QT prolongation Calcium gluconate 10% 10ml over 10 minutes Hypo<2.2, hyper>2.6

Question 358

S&S of hyperkalaemia? ECG features? Tx(and hypocalcaemia)?

Answer 358

Metabolic acidosis, arrhythmias, muscle weakness, reduced reflexes, diarrhoea Absent P waves, prolonged QRS, peaked/ tall tented T waves, sine wave pattern Calcium gluconate

Question 359

Avoid nitrofurantoin when?

Answer 359

In the 3rd trimester as risk of neonatal haemolysis--> amoxicillin= safe

Question 360

Mode of action of biguanide(metformin)? SEs? Weight?

Answer 360

Improves insulin insensitivity in liver/ muscle, suppresses hepatic gluconeogenesis Nausea, diarrhoea, MALA(take care if eGFR<45, stop if eGFR <30) Neutral

Question 361

Mode of action of sulfonylureas(gliclazide)? SEs? Weight?

Answer 361

Enhances insulin secretion Hypoglycaemia Increased weight

Question 362

Mode of action of thiazolidinedione(pioglitazone)? SEs? Weight?

Answer 362

PPARGy agonist which improves insulin sensitivity in liver/ muscle/ fat, suppresses hepatic gluconeogenesis Oedema, HF, post-menopausal OP, bladder cancer Increased weight

Question 363

Mode of action of DDP4i(linagliptin)? SEs? Weight?

Answer 363

Increases GLP-1 --> incretin effect Pancreatitis, nasopharyngitis Neutral

Question 364

Mode of action of a-glucosidase inhibitor(acarbose)? SEs? Weight?

Answer 364

Reduces intestinal glucose absorption Bloating, flatulence, diarrhoea Neutral

Question 365

Mode of action of GLP-1 analogue(exenatide)? SEs? Weight?

Answer 365

Injection, acts via 'incretin effect' give if BMI>35/ >33 + Asian Nausea, diarrhoea, pancreatitis Reduced weight

Question 366

Mode of action of SGLT-2i (-gliflozin)? SEs? Weight?

Answer 366

Inhibits renal glucose reabsorption Euglycaemic DKA, genital infections Neutral

Question 367

Mode of action of insulin? SEs? Weight?

Answer 367

Injection Hypoglycaemia, lipodystrophy

Question 368

Antiemetic to give for vertigo/ motion sickness/ vestibular disorders? Post-operatively? Palliative care? Chemo-induced? Parkinson's? Hyperemesis gravidarum?

Answer 368

Cyclizine Ondansetron Cyclizine, haloperidol, levopromazine Acute= ondansetron, delayed= metoclopramide Domperidone Promethazine

Question 369

Drugs that cause hyperglycaemia?

Answer 369

Steroids, antipsychotics, thiazides, Beta blockers, tacrolimus

Question 370

Drugs that cause constipation?

Answer 370

Opioids, iron, CCBs, some diuretics, some antiemetics, some antiepileptics, some Parkinson's medications, antacids that contain calcium, anticholinergics- antidepressants, antihistamines, incontinence meds, antipsychotics

Question 371

Drugs that cause diarrhoea?

Answer 371

Antibiotics(c.diff,) colchicine, metformin, PPIs, antacids that contain magnesium, laxatives

Question 372

Drugs that cause urinary retention/ urinary incontinence?

Answer 372

Opioids, anticholinergics Alpha- blockers, diuretics, anticholinesterase inhibitors, clozapine

Question 373

Drugs that cause confusion?

Answer 373

Opioids, sedatives, anticholinergics

Question 374

Drugs that cause falls?

Answer 374

Benzos, antidepressants esp TCAs & SNRIs, MAO, antipsychotics, opiates, most antihypertensives, Parkinson's meds- ropinirole, selegiline, antiepileptics

Question 375

Drugs that cause osteoporosis?

Answer 375

Steroids, PPIs, LHRH agonists- bureslin, goreslin

Question 376

Drugs that cause HTN? High cholesterol

Answer 376

NSAIDs, steroids, oral contraceptives, mirabegron Steroids, thiazides

Question 377

Drugs that cause hypokalaemia?

Answer 377

Loop diuretics, thiazides, steroids, salbutamol

Question 378

Drugs that cause hyperkalaemia?

Answer 378

K+ sparing diuretics, ACE-i, ARBs, unfractionated heparin/ LMWH, blood transfusion

Question 379

Drugs that cause hyponatraemia?

Answer 379

Lithium, demeclocycline

Question 380

Drugs that cause hypernatraemia?

Answer 380

SSRIs, TCAs, carbamazepine, opiates, PPIs

Question 381

Most likely to worsen Parkinson's?

Answer 381

Antipsychotics (haloperidol,) antiemetics(metoclopramide,) antidepressants

Question 382

Most likely to worsen MG?

Answer 382

Antibiotics, Beta-blockers, local anaesthetic, sedating drugs

Question 383

Most likely to worsen psoriasis?

Answer 383

Beta-blockers, lithium, some ABx

Question 384

Most likely to worsen HF?

Answer 384

NSAIDs, CCBs- verapamil, thiazolidinediones(pioglitazone), fleicanide

Question 385

Drugs to avoid in Parkinson's?

Answer 385

Typical antipsychotics: chlorpromazine, haloperidol(D2 antagonists) Atypical antipsychotics: clozapine, amisulpiride, risperidone, quetiapine, olanzapine(D2 & 5-HT antagonists- less EP SEs than typicals) Antiemetics- chlorpromazine, metoclopramide, prochlorperazine Antidepressants- phenelzine, tranylcypromine, isocarboxazid, amoxapine(act on different receptors but can have bad SEs when used in combination with Parkinson's disease meds)

Question 386

Drugs impairing renal function?

Answer 386

DRUGS: diuretics, ACE-i, ARBs, metformin, NSAIDs

Question 387

Opiate doses are usually prescribed to the nearest what?

Answer 387

5mg

Question 388

Sick day rules for diabetics?

Answer 388

Contact diabetes team keep taking diabetes medications ASAP, check blood sugars at least every 4 hours(6 times,) inc during the night/ be aware of the signs of hyperglycaemia, stay hydrated- unsweetened & eat little and often, T1DM= check ketones- when BS 15mmol/ more or 13mmol/L if using insulin pump--> contact team, unwell when taking SGLT2- stop taking them- check BSs and ketones, sip sugary drinks/ suck on glucose tablets/ sweets

Question 389

Causes of oculogyric crisis?

Answer 389

Phenothiazines e.g. chlorpromazine, levomepromazine, haloperidol, metoclopramide, post encephalitic Parkinson's disease

Question 390

Name for vitamin K for reversing warfarin? Dabigatran? Apixaban/ rivaroxaban?

Answer 390

Phytomenadione Idarucizumab/ andexanet alfa

Question 391

300mg aspirin is the general dose for what? What is the prophylactic dose?

Answer 391

Stroke & ACS- rarely given beyond 2 weeks 75mg

Question 392

It is recommended that the CHD should not continued beyond what age? Health benefits of the CHC? Cons?

Answer 392

50 y/o Reduced risk of ovarian, endometrial and colorectal cancer; predictable bleeding patterns; reduced dysmenorrhoea & menorrhagia; management of PCOS/ endometriosis and premenstrual syndrome sx, improving acne, reducing menopausal symptoms, maintaining bone mineral density in peri-menopausal females under the age of 50 y/o Small risk blood clots, mood swings, breast tenderness,

Question 393

COCs contain what? Termed what? Those with varying amounts? Oestrogens and progesterones usually used? 1st line normally?

Answer 393

Fixed amount of an oestrogen and progestogen= 'monophasic' 'Multiphasic' Ethinylestradiol, mestranol, estetrol & estradiol/ levonorgestrel or norethisterone Monophasic prep of levonorgestrel or norethisterone + 30 micrograms or less of ethinylestradiol

Question 394

Microgynon 30 ED has how much ethinylestradiol/ levonorgestrel? Yasmin? (both monophasic 21-day preps) Qlaira? (multiphasic 28-day prep) Loestrin? Cilest? Marvelon?

Answer 394

30mcg/ 150mcg Ethinylestradiol 30mcg & drospirenone 3mg Estradiol valerate/ dienogest Ethinylestradiol and norethisterone Ethinylestradiol and norgestimate Ethinylestradiol and desogestrel

Question 395

Get what during 7 day hormone free interval on COC? What checked annually? Discontinued how long prior to major elective surgery- surgery to the legs or pelvis/ involves prolonged immobilisation of a lower limb? Recommenced when?

Answer 395

Monthly withdrawal bleed BMI & BP 4 weeks 2 weeks after full remobilisation

Question 396

1st line COC? For premenstrual syndrome? Tx of acne and hirsutism? Stopped how long after acne controlled?

Answer 396

Microgynon or Leostrin Yasmin and other COCPs containing drospirenone- continuous use vs cyclical may be more effective Cyproterone acetate i.e. co-cyprindiol- 3 months

Question 397

CIs to the CHC(UKMEC 4)? BMI>35 is what? What reduces effectiveness?

Answer 397

Uncontrolled HTN particularly >/=160/ >/= 100, migraine w/ aura, hx of VTE, 35 y/o>, smoking >15 cigarettes a day, major surgery w/ prolonged immobility, vascular disease/ stroke, IHD/ cardiomyopathy/ AF, liver cirrhosis & tumours, SLE & APS, known/ suspected pregnancy, breastfeeding<6 weeks post-partum/ <3 weeks in non-breastfeeding women with VTE RFs, breast cancer/ cancer within last few years, BRCA genes UKMEC 3 Severe diarrhoea>24 hours and vomiting within 3 hours of taking

Question 398

When should the pill be started? What is needed after this? Switching between COCPs/ traditional POP/ from desogestrel?

Answer 398

On 1st day of the cycle, same time each day 7 days of extra contraception Finish one pack, then immediately start the new pack without the pill-free period POP= 7 days condoms needed Desogestrel= can switch immediately(inhibits ovulation)

Question 399

When can the COC be started after childbirth without VTE RFs(not breastfeeding)? With RFs?

Answer 399

3 weeks, 6 weeks (barrier methods for 1st 7 days)

Question 400

Forms of progestogen- only contraception? Mechanism?

Answer 400

Oral, injectable, subdermal, intra-uterine form Changes to cervical mucus affecting sperm penetration, endometrial changes affecting implantation, ovulation suppression

Question 401

Injections of progestogen- only contraceptives? Benefit who? Cons?

Answer 401

Medroxyprogesterone acetate and norethisterone enantate, implant= etonogestrel(suppress ovulation) Those with menorrhagia or dysmenorrhoea, can have them whilst breastfeeding Weight gain, mood changes, headaches

Question 402

Depot administered how often? Considerations? Delayed return of fertility of up to how long after discontinuation?

Answer 402

13 weeks Review every 2 years, >50 y/o= switch & with RFs for osteoporosis 1 year

Question 403

Etonogestrel implant provides highly effective contraception for how long? Pros & cons?

Answer 403

3 years Reversible and periods return quickly, periods= light/ non- existent Periods may become irregular- more often lighter or stop altogether, SEs- usually settle after first few months

Question 404

HRT, high cholesterol, UTIs

Question 405

Pros and cons of POP?

Answer 405

Less risks than COC, many women= CI for COC, can use when breastfeeding Periods--> irregular, some= SEs, have to be more exact with time, small risk of BRCA

Question 406

Pros and cons of contraceptive patch and vaginal ring?

Answer 406

Don't have to remember pill, periods= often lighter, less painful and more regular, effective during sickness and diarrhoea Some= skin irritation, may come off, similar risks to pill 3 weeks in & one week without it, periods regular Some felt during sex, may irritate vagina & cause soreness/ discharge, similar risks to pill

Question 407

What is a 'missed pill'? Advice <72 hours since last pill? >1 pill> 72 hours since last pill?

Answer 407

One that is 24 or more hours late/ 48 hours since last pill was taken Take ASAP, no extra protection needed Take most recent missed pill- even if more than 1, condoms needed for 7 days, day 1-7 packet= emergency contraception Day 8-14= NO EMERGENCY NEEDED Day 15-21= NO EMERGENCY NEEDED- go back to back with next pack and skip pill-free period

Question 408

Methods of emergency contraception? Most effective? Can cause what?

Answer 408

Levonorgestrel(progestogen pill) i.e. Levonelle- usually 1.5mg Levonorgestrel(may need higher if BMI>26 or weight>70kg or taking certain meds)= within 72 hours UPSI Ulipristal i.e. EllaOne= within 120 hours Copper coil= within 5 days UPSI/ estimated date of ovulation Copper coil- PID, removed at next period/ left in long-term

Question 409

If ovulated already, better to use what? Who shouldn't use the progestogen- morning after pill? Avoid breastfeeding for how long after dose taken?

Answer 409

Copper coil Severe gut disease, hx ectopic pregnancy/ molar pregnancy, porphyria 8 hours

Question 410

Ulipristal less effective when? Can't take with what? Wait how long before taking COC/ POP? Condom for how long with COCP/ POP? Avoid breastfeeding for how long after?

Answer 410

Weight>80kg/ BMI>30 Severe asthma 5 days 7 days/ 2 days 1 week- express & discard

Question 411

When can the IUCD be inserted safely after childbirth? CIs to coils? Seen to check threads how long after insertion?

Answer 411

Beyond 4 weeks PID/ infection, immunosuppression, pregnancy, unexplained bleeding, pelvic cancer, uterine cavity distortion e.g. by fibroids, copper= Wilson's disease 3-6 weeks after

Question 412

Risks when inserting the coil? Before removal, what is needed? Exclude what 3 things with non-visible threads?

Answer 412

Bleeding, pain, vasovagal reactions, uterine perforation, PID, expulsion= highest in first 3 months Abstain from sex for 7 days/ use condoms- risk of pregnancy Expulsion, pregnancy, uterine perforation

Question 413

Ix for lost coil?

Answer 413

USS, AXR & pelvic X-ray, hysteroscopy or laparoscopic surgery

Question 414

4x types of IUS? How does it work? When can it be inserted up until without additional protection needed? Problematic bleeding common when?

Answer 414

Mirena= 5 years Levosert= 5 years Kyleena= 5 years Jaydess= 3 years Thickens mucus, alters endometrium, inhibits ovulation in small number Up to day 7 1st 6 months- suggested COCP for 3 months

Question 415

Which epilepsy meds are enzyme inducers? Effects on contraception methods? What may need to be adjusted?

Answer 415

Carb, eslicarbazepine, oxcarbazepine, phenoarbital, phenytoin, primidone, topiramate COCP: oestrogen needs to be 50mcg POP, progestogen implants, combined transdermal contraceptive patch= not recommended Emergency= Levo increased to 3mg Depot injection= more frequently needed (barrier/ coil recommended) Lamotrigine

Question 416

All HRT contains what? Some types contain what too? You don't need a progestogen when? Options to ease symptoms just in the vaginal area?

Answer 416

Oestrogens A progestogen hormone too- reduces the risk of endometrial cancer If you've had a hysterectomy or had a Mirena coil fitted Cream, pessary or vaginal ring containing oestrogen

Question 417

HRT options? If you've just finished periods/ still having periods, normally advised to use what? How does monthly cyclical HRT work? Advised for who?

Answer 417

Patches, tablets & topical gel or spray Oestrogen is taken every day- progestogen is added in for 14 days of each 28 day tx cycle--> regular bleed every 28 days Women with menopausal sx, but still having regular periods

Question 418

May switch to continuous combined HRT if what 2 things?

Answer 418

Taking cyclical combined HRT for at least 1 year OR it's been at least 1 year since their last menstrual period

Question 419

How does continuous HRT work?

Answer 419

Take an oestrogen and a progestogen every day, may have irregular bleeding in the first 3-6 months after starting this form of HRT- see doctor if >6 months/ bleeding after months without

Question 420

What HRT if you've had a hysterectomy? What is sometimes prescribed in menopausal women who complain of low sexual desire if HRT alone is not effective? How long for hot flushes & night sweats/ changes to vagina & vulva to improve? HRT trial of how long normally?

Answer 420

Containing oestrogen only Testosterone gel- specialist Few weeks/ 1-3 months 3 months, reduce gradually

Question 421

Non-hormonal tx for menopause initially/ when CI to HRT? Common SEs of clonidine?

Answer 421

Lifestyle changes, CBT, clonidine (agonist of alpha-adrenergic and imidazoline receptors,)- for hot flushes and vasomotor sx, SSRIs, venlafaxine, gabapentin Dry mouth, headaches, dizziness & fatigue, sudden withdrawal--> rapid increases in BP & agitation

Question 422

Risks of HRT? Exceptions? Reduce VTE risk?

Answer 422

Increased risk of BRCA, endometrial cancer, VTE, stroke, CAD, inconclusive about ovarian cancer Not increased in women under 50 y/o, endometrial cancer in those without a uterus, CAD in those with oestrogen-only HRT Use patches> pills

Question 423

CI to HRT?

Answer 423

Undiagnosed abnormal bleeding, endometrial hyperplasia or cancer, BRCA, uncontrolled HTN, VTE, liver disease, active liver disease, active angina/ MI, pregnancy

Question 424

Who is tibolone helpful for? It's used as a form of what? Stop how long before major surgery?

Answer 424

Those with a reduced libido- can cause irregular bleeding A form of continuous combined HRT 4 weeks

Question 425

Oestrogenic SEs of HRT? Progestogenic SEs? Do what?

Answer 425

N& bloating, breast swelling, breast tenderness, headaches, leg cramps Mood swings, bloating, fluid retention, weight gain, acne and greasy skin Change the type or route of administration/ form of progesterone

Question 426

Synthetic glucocorticoids e.g. pred mimic the effect of what and result in what?

Answer 426

Endogenous steroids- modulate carbohydrate metabolism--> hyperglycaemia

Question 427

Rapid-acting insulins? Short-acting?

Answer 427

Insulin aspart(Novorapid,) insulin lispro (Humalog) Actrapid, Humulin S

Question 428

Intermediate-acting insulins?

Answer 428

Isophane insulin, insulin aspart protamine, insulin lispro protamine

Question 429

Long-acting insulins? Pre-mixed?

Answer 429

Detemir(Levemir,) glargine (Lantus) Novomix 30(30% insulin aspart, 70% insulin aspart protamine) Humalog Mix 25(25% insulin lispro, 75% insulin lispro protamine) Biphasic isophane insulin (Humulin M3- 30% short-acting, 70%= isophane)

Question 430

If K+ is over what value, don't give any supplementation? Only use what in liver failure as excess Na+ may cause ascites? Avoid what in acute renal failure? Chronic renal failure?

Answer 430

4.5mmol/L 5% dextrose Potassium supplementation Excess fluids, Na+ and potassium

Question 431

If hx of alcohol excess/ poor nutrition, give what before giving any 5% dextrose? Avoid what in brain haemorrhage and re-feeding syndrome?

Answer 431

Pabrinex- can precipitate Korsakoff's syndrome Dextrose

Question 432

Dalteparin in CI in patients with what?

Answer 432

Heparin-induced thrombocytopenia, conditions putting at a high risk of bleeding complications e.g. acute gastroduodenal ulcer, cerebral haemorrhage, conditions causing a predisposition to bleed, serious coagulation disorders, those who have suffered a recent stroke (within 3 months,) unless due to a systemic emboli

Question 433

When may unfractionated heparin be preferred over LMWH in tx of a DVT/ PE?

Answer 433

Renal impairment(it can be reversed)

Question 434

Metformin is contraindicated for patients with significant what?

Answer 434

Patients with significant renal impairment or who are acutely unwell and tissue hypoxia is likely

Question 435

Morphine and other opioid analgesics may cause what especially in the early postoperative period? Other drugs commonly causing urinary retention?

Answer 435

Urinary retention Anticholinergics, general anaesthetics, alpha-adrenoceptor agonists, benzos, NSAIDs, CCBs, antihistamines, alcohol

Question 436

Dose of folic acid up until week 12 of pregnancy? Those with a low risk of conceiving a child with a neural tube defect?

Answer 436

5mg PO OD/ 400 micrograms daily before conception

Question 437

HRT should be stopped if the BP rises above what?

Answer 437

Systolic 160 mmHg or diastolic 95 mmHg

Question 438

Common doses of ibuprofen, codeine and co-codamol 8/500 and 30/500?

Answer 438

200-400mg TDS/ 30-60mg QDS/ 2 tabs QDS

Question 439

Common doses of metoclopramide/ cyclizine, amoxicillin/ clarithromycin, lansoprazole/ omeprazole?

Answer 439

10 mg TDS/ 50mg TDS 500mg TDS/ 500mg BD 15-30mg OD/ 20-40mg OD

Question 440

Common doses of clopidogrel, simvastatin, atenolol, ramipril, bendro, furosemide and amlodipine?

Answer 440

75-300mg OD 10-80mg ON 25-100mg OD 1.25-10mg OD 2.5mg OD 20mg OD- 80mg BD 5-10mg OD

Question 441

Common doses of levothyroxine and metformin?

Answer 441

25-200mcg OD, 500mg OD/ 1g BD

Question 442

FBC, U&Es, LFTs during antipsychotic therapy? Lipids and weight? Fasting blood glucose and prolactin? BP? ECG? CVR assessment?

Answer 442

At the start, annually, clozapine= more frequent monitoring of FBC(initially weekly) At the start of therapy, 3 months & annually Start, 6 months, annually Baseline, frequently during dose titration Baseline Annually

Question 443

How long to monitor patients after withdrawal of antipsychotic medication for S&S of relapse? Reduce clozapine dose over how long?

Answer 443

2 years 1-2 weeks

Question 444

Normal mini-mental score?

Answer 444

A score of 25 or higher

Question 445

Tx for exacerbations of chronic bronchitis? Uncomplicated CAP? Pneumonia from atypical pathogens? HAP?

Answer 445

Amoxicillin/ tetracycline/ clarithromycin Amoxicillin Clarithromycin Within 5 days admission= co-amoxiclav/ cefuroxime/ >5 days= piperacillin with tazobactam/ ceftazidime/ ciprofloxacin

Question 446

Tx of acute pyelonephritis? Acute prostatitis?

Answer 446

Broad-spec cephalosporin or quinolone Quinolone or trimethoprim

Question 447

Tx for impetigo? Cellulitis? Near the eyes/ nose? Erysipelas? Animal/ human bite? Mastitis during breast-feeding?

Answer 447

Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread Flucloxacillin- clari/ erythro/ doxy if pen-allergic Co-amoxiclav- clari & metronidazole if pen-allergic Flucloxacillin- same as cellulitis Co-amoxiclav- doxy & metro if pen-allergic Flucloxacillin

Question 448

Tx for throat infections? Sinusitis? Otitis media? Otitis externa? Periapical/ periodontal abscess? Gingivitis?

Answer 448

Phenoxymethylpenicillin Phenoxymethylpenicillin Amoxicillin Flucloxacillin Amoxicillin Metronidazole

Question 449

Tx for gonorrhoea? Chlamydia? PID? Syphilis? BV?

Answer 449

IM ceftriaxone Doxy or azithromycin Oral ofloxacin & oral metronidazole/ IM ceftriaxone + oral doxycycline + oral metronidazole Benzathine benzylpenicillin/ doxy or erythromycin Oral or topical metronidazole or topical clindamycin

Question 450

Tx for 1st episode of c.difficile? Second/ subsequent? Campylobacter enteritis? Salmonella? Shigellosis?

Answer 450

Oral vanc/ oral fidaxomicin Clarithromycin Cipro Cipro

Question 451

Avoid what drugs in breast-feeding?

Answer 451

Cipro, tetracyclines, chloramphenicol, sulphonamides, lithium, benzos, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, amiodarone

Question 452

Tx for prophylaxis of meningitis in close contacts?

Answer 452

Oral ciprofloxacin or rifampicin

Question 453

When are LFTs checked when taking statins? 1st-line tx for surgical patients at low risk of VTE?

Answer 453

Baseline, 3 and 12 months Anti-embolism stockings

Question 454

Prophylaxis of VTE in elective hip replacement? Elective knee replacement? Fragility fractures of the pelvis, hip and proximal femur?

Answer 454

LMWH for 10 days followed by aspirin for 28 days/ LMWH for 28 days w/ anti-embolism stockings until discharge/ rivaroxaban Aspirin for 14 days/ LMWH for 14 days combined with anti-embolism stockings/ rivaroxaban 1 month of: LMWH from 6-12 hours after surgery or fondaparinux sodium starting 6 hours after surgery- provided low risk of bleeding

Question 455

Tx for otitis externa? Otitis media?

Answer 455

Analgesia, topical acetic acid 2% or topical antibiotic +/- steroid: similar cure at 7 days, cellulitis/ extends outside= flucloxacillin 250mg QDS, severe= 500mg QDS Amoxicillin, allergy= clarithromycin or erythromycin, 2nd line= co-amoxiclav (5-7 days)

Question 456

Tx for sinusitis above 10 days?

Answer 456

High-dose nasal corticosteroid mometasone furoate

Question 457

Presentation and tx for epiglottitis?

Answer 457

Drooling, inspiratory stridor, tripod condition, fever, looks septic IV ceftriaxone and dexamethasone- hypersensitivity to penicillins/ cephalosporins= chloramphenicol Blood culture & close contact prophylaxis with rifampicin (Aged between 2 and 5 y/o)

Question 458

Tx for viral induced wheeze?

Answer 458

<5y/o= supplementary O2, salbutamol and inhaled corticosteroids, montelukast

Question 459

Tx of paediatric bronchiectasis? Same for what?

Answer 459

Amoxicillin, clarithromycin or doxycycline>12 y/o High risk tx failure= co-amoxiclav or ciprofloxacin IV 1st line= co-amoxiclav, piperacillin with tazobactam or ciprofloxacin Acute cough

Question 460

Tx for CAP? HAP in children?

Answer 460

1 month and over oral amoxicillin, clarithromycin, doxy for >12 y/o, erythromycin in pregnancy Severe: oral or IV co-amoxiclav, clarithromycin or erythromycin if atypical Oral co-amoxiclav, alternative/ unsuitable= clarithromycin Severe= piperacillin with tazobactam, ceftazidime or ceftriaxone MRSA= add teicoplanin or vancomycin or linezolid

Question 461

Tx for lung infection in CF?

Answer 461

Flucloxacillin for staph, amoxicillin in h.influenzae, pseudomonas= ciprofloxacin

Question 462

Presentation and tx of bronchiolitis?

Answer 462

Rhinorrhoea, respiratory distress, apnoeas, <2 y/o usually Adequate intake, saline nasal drops and nasal suctioning, O2 if <92%, ventilatory support if needed Palivizumab= monthly injection

Question 463

Mnemonics for Crohn's and UC? Tx?

Answer 463

NESTS: no blood/ mucus, entire GI tract, kip lesions, terminal ileum- most affected & transmural inflammation, smoking= a RF CLOSEUP: continuous inflammation, limited to colon and rectum , only superficial mucosa affected, smoking= protective, excrete blood & mucus, use amino salicylates, PSC Oral pred/ IV hydrocortisone--> azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab Mild--> moderate disease= aminosalicylate e.g. mesalazine oral or rectal, 2nd line= corticosteroids e.g. prednisolone Severe: IV corticosteroids e.g. hydrocortisone, 2nd line= IV ciclosporin Maintaining remission= aminosalicylate e.g. mesalazine oral/ rectal, azathioprine, mercaptopurine

Question 464

Tx for GORD in breast-fed infants in non-pharm methods failed? Formula-fed infants? Not use what to tx regurgitation as an isolated sx?

Answer 464

Alginic acid for 1-2 weeks PPIs or histamine2- receptor antagonists

Question 465

4-week trial of PPIs in who for Paeds?

Answer 465

Regurgitation with one or more of unexplained feeding difficulties, distressed behaviour or faltering growth

Question 466

KCL hospital criteria for liver transplantation?

Answer 466

Arterial pH<7.3 24 hours after ingestion/ all of: PTT>100 seconds, creatinine>300 micromol/L, grade III or IV encephalopathy