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PSA Flashcards

1
Q

ƒPatient taking ACEi (ramipril) with dropping renal function - what to do?

A
  • If creatine rises by more than 20%/eGFR drops by >15 – keep dose and check U&E in 2wk
  • Only if creatinine rises by 30-50%/eGFR <30 – reduce and reassess U&E in 1wk
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2
Q

Calculating ml dose knowing mg and concentration

A

mg dose x 1/concentration (in units mg/ml) = dose in mL

NOTE if concentration is 1% –> 1g in 100mL –> 1000mg in 100mL –> 10mg/mL –> this value can then be used for the above calculation

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3
Q

Drugs to avoid in renal failure (eGFR <30)?

A

Key: NSAIDs, ACEi (& ARBs)

Other:

  • Abx: tetracyclines, nitrofurantoin, aminoglycosides
  • Allopurinol (accumulates in renal dysfunction)
  • Lithium
  • Metformin
  • IV contrast
  • Statins used with caution

Drugs harmful in AKI = CANDA: Contrast (keep very hydrated), Aminoglycosides (Gent), NSAIDs, Diuretics, ACEi

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4
Q

Correcting hyperglycaemia in DM:

  • How much does 1 unit of rapid-acting insulin reduce BM by?
  • How much to adjust insulin dose by at one time?
  • Target insulin dose?
  • Types of insulin?
A

ASK PATIENT - rule of thumb is 100/total daily dose (TDD)

  • E.g. TDS Actrapid 7 units + 18U lantus = 39U TDD –> 100/39 = 2.5
  • Generally it is roughly 3mmol/L

10%

Target glucose: 4-10 (aim for 7-8)

  • Fasting plasma glucose:
    • Waking: 5-7mmol/litre
    • Before meals: 4-7mmol/litre

Insulins:

  • Short-acting (before meals) - insulin aspart/lispro
    • Influence daytime meal measurements
  • Intermediate-acting - isophane insulin
  • Long-acting ‘basal’ (OD/BD - breakfast and bed) - insulin detemir/glargine
    • Influence pre-breakfast measurement
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5
Q

Enzyme inducers/inhibitors affect what drugs? Which drugs are enzyme inducers and inhibitors?

A

Affected drugs: Warfarin, COCP, steroids, statins

Enzyme inducers (decrease efficacy): CRAPS

  • Carbamazepine
  • Rifampicin
  • bArbituates (amobarbital & alcohol chronically)
  • Phenytoin (for epilepsy)
  • St John’s wort (& sulphonylureas - gliclazide, tolbutamide)

Enzyme inhibitors (potentiate effects): GO DEVICES

  • Grapefruit juice
  • Omeprazole
  • Disulfiram (support alcohol abstinence)
  • Erythromycin
  • Valproate
  • Isoniazid
  • Ciprofloxacin (& Cimetidine)
  • Ethanol (acutely)
  • Sulphonamides (trimpethoprim, sulfasalzine)
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6
Q

C/I drugs in Peptic Ulcer Disease?

A

NSAIDs, Aspirin

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7
Q

C/I drugs in chronic HF?

A

CCB (verapamil), antiarrhythmics (amiodarone is the safest), TCAs, NSAIDs, corticosteroids

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8
Q

C/I drugs in asthma?

A

B-blockers, NSAIDs

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9
Q

C/I drugs in heart block?

A

Beta-blockers, digoxin, verapamil

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10
Q

C/I drugs in Parkinson’s disease?

A

Anti-psychotics e.g. haloperidol –> EPSE

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11
Q

Drugs for cardiac arrest?

A

DC shock (150J biphasic)

Adrenaline 1mg IV (10ml 1:10,000)

Amiodarone 300mg IV (if shockable rhythm)

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12
Q

Drugs for anaphylaxis?

A

Adrenaline 0.5mg IM (0.5ml 1:1000)

Hydrocortisone 200mg IV

Chlorphenamine 10mg IV

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13
Q

Seizure drugs?

A

Lorazepam 4mg IV (diazepam 10mg PR if no IV access)

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14
Q

Hypoglycaemia drugs?

A

20% glucose 75ml IV (repeat as needed) over a time period up to 20 mins

  • 2nd line - glucagon 1mg IM (if no IV access, not ideal if anticoagulated as IM + causes nausea/flushing
  • NOTE: risk of aspiration of glucose gel in an unconscious patient
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15
Q

Hyperkalaemia drugs?

A

10% Ca gluconate 10ml IV over 5 mins

THEN

10 units Actrapid insulin added over 30 mins AND 100ml 20% glucose

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16
Q

Bradycardia drugs?

A

Atropine 500mcg IV (repeat every 3-5mins to max 3mg)

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17
Q

SVT drugs?

A

Adenosine 6mg IV (then 12mg then 12mg)

  • Must be given as bolus + flushed quickly via large vein
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18
Q

VT drugs (without adverse signs)?

A

Amiodarone 300mg IV over 20-60mins

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19
Q

Rapid tranquillisation of agitated patient @risk to self/others - drugs?

A

Lorazepam 1-2mg PO/IM or Olanzapine 5-10mg PO/IM

  • Give oral if possible, give half if elderly/renal impairment
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20
Q

Key side effects of anti-HTNs?

  • ACEi
  • CCB
A

ACEi: dry cough

CCB: pedal oedema

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21
Q

Key SEs of anti-diuretics?

  • ALL, loop, K+ sparing
A

ALL: hypokalaemia (except K+ sparing)

Loop: hypocalcaemia

K+ sparing: hyperkalaemia

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22
Q

Hyperglycaemic drug S/Es?

A

Metformin: weight loss, LA

Sulphonylureas (e.g. gliclazide): hypoglycaemia

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23
Q

Antiarrhythmic drug S/Es?

A

Amiodarone: thyroiditis, pul fibrosis

Digoxin toxicity: xanthopsia (yellow/orange tinge to vision)

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24
Q

Drugs associated with hyponatremia?

A

DACC: Diuretics, Antidepressants, Chlorpromazine (antipsychotic), Carbamazepine (anti-convulsant)

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25
Q

Drugs associated with hypokalaemia?

A

Salbutamol, insulin, diuretics (except K+ sparing)

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26
Q

Drugs associated with hypercalcaemia?

A

thiazide diuretics

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27
Q

Drugs associated with hypocalcaemia?

A

loop diuretics, bisphosphonates

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28
Q

What drug is photosensitivity associated with?

A

Tetracyclines

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29
Q

What drugs cause Steven-Johnson syndrome/erythroderma?

A

sulphur-based drugs (sulphonamides, sulphonylureas), antiepileptics (gabapentin, lamotrigine, carbamazepine)

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30
Q

Drugs commonly causing constipation?

A

Opioids (codeine, tramadol)

Anticholinergics (block acetylcysteine - neurotransmitter):

  • TCAs e.g. amitryptiline
  • Antihistamines e.g. chlorphenamine/cetirizine
  • Antiparkinsonian e.g. levodopa
  • Neuroleptics (antipsychotics) e.g. olanzapine, risperidone, chlozapine
  • Bladder instability e.g. oxybutynin
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31
Q

Drugs commonly causing confusion?

A

Anticholinergic drugs (TCAs, antihistamines, antiparkinsonian, antipsychotics, bladder instability)

Opioids, Benzos (diazepam)

Glucocorticoids (e.g. pred) esp. in elderly

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32
Q

Drugs commonly causing diarrhoea?

A

Antibiotics

Metformin

PPIs

Bisphosphonates

SSRIs (citalopram, sertraline), lithium

Colchicine, mg-containing drugs,

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33
Q

Drugs commonly causing dyspepsia?

A

Anti-inflammatory meds (aspirin, ibuprofen, celecoxib)

Bisphosphonates (alendronate)

Corticosteroids (pred)

Macrolides (clari)

Metformin

Theophylline

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34
Q

Drugs commonly causing falls/dizziness?

A

anti-HTN

CNS suppressants (opioids, benzos, anti-depressants, anti-psychotics)

Diuretics (furosemide)

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35
Q

Drugs that commonly cause hearing loss?

A

Aminoglycosides (gent, cisplatin)

Loop diuretics (furosemide)

Phosphodiesterase type-5 inhibitors (tadalafil) - used for pul HTN

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36
Q

Drugs that commonly cause tremor?

A

B-2-agonist (salbutamol)

Levothyroxine, Lithium

Cyclosporin

Nicotine

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37
Q

NSAID important adverse drug reactions?

A

Gastrotoxicity

Renal impairment

HTN

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38
Q

Loop diuretics important adverse drug reactions?

A

e.g. furosemide

Dehydration

Renal impairment

Hypokalaemia

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39
Q

Opioid important adverse drug reactions?

A

e.g. morphine

Constipation

Confusion

Drowsiness

Urinary retention

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40
Q

Antipsychotic drug monitoring

A

Baseline - BMI, blood lipids, fasting blood glucose, prolactin

1 month - fasting BM

3 months - BMI (check regularly until 3 months), blood lipids

4-6 months - fasting BM

6 months - BMI, blood lipids, prolactin

Every year - BMI, blood lipids, fasting blood glucose, prolactin, FBC, U&E, LFTs

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41
Q

Treatment of high INR? Target?

A
  • Any bleeding: stop Warfarin AND IV vit K slowly
    • If major bleed = ADD dried PCC/FFP
    • INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
  • INR >8: stop Warfarin AND oral Vit K
    • INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
  • INR 5-8: miss dose of Warfarin –> reduce maintenance dose

Target: 2.5 (2-3 range)

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42
Q

How is degree of anticoagulation assessed if on UFH IV?

A

aPTT

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43
Q

If prescribing insulin what are the units?

A

The units are UNITS (do not write an abbreviation)

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44
Q

How to search for adverse drug reactions in medicines complete?

A

POISONING in main bar –> emergency treatment

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45
Q

Asthma - drug Tx?

A

ACUTE:

  • Burst:
    • SABA (spacer up to 10 puffs every 20 mins –> nebs)
    • Ipratropium Bromide (add to nebs if poor response/severe, every 4-6hrs)
    • Corticosteroids (min 5-day course, give within 1 hour, give IV if can’t take orally)
  • Other Tx options:
    • IV Magnesium sulfate (STAT dose if poor response above/severe) - consult senior before use
    • IV salbutamol (if on ventilation) - consult senior before use
    • IV Aminophylline - consult senior before use, requires ITU setting

Long-term Mx (>16yrs):

  • SABASABA (reliever)
  • SABA + ICS (preventer)
  • SABA + ICS + LTRA (leukotrine receptor antagonist e.g. montelukast)
  • SABA + ICS + LABA (+ LTRA stopped unless good response)
  • SABA + MART (ICS + LABA COMBO) (+ LTRA)
  • NOTE: maintenance & reliever therapy (MART) - used as preventer & maintenance inhaler
  • Specialist input (e.g. for oral steroids)
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46
Q

COPD - drug Tx?

A

Medical pathway:

  • 1 - SABA/SAMA (ipratropium)
  • 2a - Steroid-responsive (eosinophilia/atopy): LABA + ICS
  • 2b - Not steroid-responsive: LABA (salmeterol) + LAMA (tiotropium)
  • 3 - LABA + LAMA + ICS
  • 4 - specialist input e.g. theophylline

Acute Exacerbation Mx:

  • 15L O2 NRM
  • Nebs - salbutamol + IpB
  • Steroids (PO pred/IV hydrocortisone)
  • Abx if infective –> prophylactic abx if persistent infections - azithromycin
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47
Q

Significance of Atorvastatin + Clarithromycin?

A

Drug-drug interaction –> risk of liver damage + rhabdomyolysis

Withhold atorvastatin

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48
Q

Critical drugs - DO NOT EMIT when put on NBM in hospital

A
  1. Parkinson’s drugs (Levodopa, Carbidopa)
  2. Antiepileptics (Na Val, Carbamazepine, Lamotrigine, Levetiracetam)
  3. Antiretrovirals (-avir)
  4. Steroids (long-term) - stopping abruptly –> Addisonian crisis

Routes –> patches, IV, NG tube

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49
Q

Opioids:

  1. Strength of different opioids
  2. Forms of oral morphine
  3. Guide to giving morphine
  4. When to give oxycodone
  5. Breakthrough analgesia
  6. Conversion between opioid doses
A

Strength:

  • Weak - codeine, dihydrocodeine
  • Moderate - tramadol (surgeons love)
  • Strong - morphine, oxycodone, buprenorphine, fentanyl

Oral morphine has 2 forms:

  • Oral morphine has 2 forms:
    • Immediate-release (e.g. oromorph) - max 4-hourly
    • Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD)

Guide to morphine:

  1. If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV dose
  2. Immediate-release PRN (max 4-hourly) –> see how much using
  3. If using a huge amount –> convert to modified-release (12/24-hourly):
    • Add up total daily PRN dose = X
    • 24-hourly = X (OD); 12-hourly = X/2 (BD)

​When to give oxycodone: renal impairment (eGFR <30mL/min)

  • Immediate-release: oxycodone oral solution, oxynorm
  • Modified-release: oxycontin
  • NOTE: same logic as above

Breakthrough analgesia:

  • Oral morphine/oxycodone
  • 1/10-1/6 of total daily dose of modified-release morphine

Example: 60mg Oromorph –> 30mg MST BD + 6-10mg breakthrough dose

Conversion - 10mg oral morphine:

  • Oxycodone - 5mg oral (x/2), 2.5mg IV (x/4)
  • Tramadol/Codeine - 100mg oral/IV (x*10) - NOTE: codeine has no IV option
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50
Q

Diabetic Ketoacidosis (DKA) - drug Tx?

A

Tx: IV FLUIDS (rehydrate) - after initial bolus give 1L 0.9% saline + 40mmol KCl over 1hr

Tx: 0.1 U/kg/hr fixed-rate INSULIN infusion (reduce ketones) + add IV 10% dextrose on reducing ketone/glucose levels

  • Insulin infusion continues even if BM normalises –> to inhibit lipolysis & prevent ketone formation (can consider stopping once ketones normal)
  • Stop short-acting insulin, maintain background insulin
  • NOTE: follow local trust guidelines for DKA Tx as varies slightly between trusts
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51
Q

Opiate overdose Tx? What if patient becomes unrousable again?

A

IV access –> STAT dose naloxone 400mcg - after 1-min of no improvement –> 800mcg

Stay by the bedside until improved resp rate

If the patient becomes unrousable again - Naloxone has a short half-life so may still be opioid toxic –> Naloxone infusion

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52
Q

Anaphylaxis drug Tx?

A

IM 0.5mg adrenaline (1:1000)

IV 10mg chlorpheniramine

IV 100mg hydrocortisone

Treat bronchospasm – salbutamol +/- ipratropium

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53
Q

Crohn’s, UC drug Tx?

A

Crohn’s & UC Mx (Crohn’s = steroids –> methotrexate; UC = 5-ASA):

  • Induction:
    • Steroids (induce remission)
    • 5-ASA (mesalazine)
  • Maintenance:
    • Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine)
    • Biologics e.g. Anti-TNF (infliximab)
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55
Q

Upper GI bleed - drugs?

A

Drugs with prognostic benefit:

  • IV Terlipressin (ADH analogue –> vasoconstriction)/Somatostatin (used for same reason)
  • Prophylactic abx - Ceftriaxone/Norfloxacin (abx)
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56
Q

Peptic ulcer disease - drug Tx?

A

Mx: consider STOPPING NSAIDs

  • stop NSAIDs
  • If H. pylori +ve: triple therapy for 7 days (PPI + 2 abx = Amox + clari/metro)
    • If pen allergic –> PPI + Clari + Metro
  • If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist e.g. cimetidine)
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57
Q

IHD - drug Mx?

A

Stable angina:

  • B-blockers - reduces HR req for activity –> reduced likelihood of mismatch in O2 supply & demand
  • GTN spray - reduce myocardial preload + reduces strain
    • RF modification –> reduced risk of progression

Acute coronary syndrome - Sx caused by sudden reduced BF to the myocardium

  • Generic ACS Mx - MONA BASH
    • ALL immediate:
      • 5-10mg Morphine IV + Nitrates (GTN spray)
      • Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor)
    • ALL long-term:
      • Continue DAPT
        • 1 year: 75mg OD Aspirin + 75mg OD Clopidogrel (or 90mg BD Ticagrelor)
        • >1yr - 75mg OD Aspirin
      • B-blocker (1.25-10mg Bisoprolol OD)
      • ACEi (1.25-10mg Ramipril OD)
      • Statin (80mg Atorvastatin OD)
  • STEMI Mx: establish coronary reperfusion ASAP
    • Sx <12hrs: PCI BUT if no PCI within 2hrs Dx –> thrombolysis (e.g. tPA - tissue plasminogen activator)
    • Sx >12hrs: invasive coronary angiography ± PCI if needed
    • PCI:
      • If having PCI give Prasugrel (instead of Clopi/Ticagrelor)
      • PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND IV unfractionated heparin during the procedure –> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) –> takes longer for endothelialization of stent so DAPT needed for 1yr
  • NSTEMI Mx: 2.5mg SC Fondaparinux (direct factor 10a inhibitor)
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58
Q

Heart failure - drug Mx?

A

Mx: MON BA (out of MONA BASH)

  • Immediate:
    • Sit the patient up (reduce venous return to heart –> less strain)
    • O2 15L/min NRM
  • Medical:
    • IV furosemide (loop diuretic) - remove excess fluid + venous dilation (reduce preload)
    • Nitrates (GTN/Isosobide Mononitrate) AND Morphine - reduce preload on the heart
  • Long-term:
    • Reduced ejection fraction - prognostic benefit:
      • B-blocker (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them
      • ACEi - reduce strain on heart
        • After the above if LVEF <35% & Sx –> mineralocorticoid antagonist e.g. spironolactone
        • 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT
      • SGLT2 inhibitors (dapagliflozin)
    • RF modification - poor glycaemic control/high cholesterol
    • Sx - diuretics e.g. furosemide
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61
Q

SVT - drug Tx?

A

Mx:

  • Haemodynamically unstable –> synchronised DC Cardioversion
  • Vagal manoeuvres (increase parasympathetic stim via vagus nerve to slow conduction via AV node)
    • Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe
  • Adenosine 6mg –> 12 mg –> 12mg
    • NOTE: if adenosine CI (e.g. asthma) –> VERAPAMIL (rate-limiting CCB)
  • Other:
    • IV B-blocker/amiodarone/digoxin
    • Synchronised DC Cardioversion
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62
Q

Atrial fibrillation - drug Tx?

A

Mx:

  • Haemodynamically unstable (≤90 BP, chest pain, acute HF) –> DC Cardioversion

OR

  • Rate control –> B-blocker (bisoprolol) OR rate-limiting CCB (verapamil - asthma)

OR

  • Rhythm control - ONLY if clear reversible cause
    • Sx onset <48hrs –> DC/chemical cardioversion (amiodarone/flecanide)
      • NOTE: IV heparin started prior to cardioversion
    • Sx onset >48hrs –> anticoagulate for 3wks –> elective cardioversion (also anticoag for 4wks after)

AND

  • Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score –> DOAC (Apixaban)
    • If metallic heart valve –> warfarin INR 3-3.5
    • Otherwise DOAC
    • NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 –> anticoagulation not recommended
    • CHF, HTN, Age ≥75rs (2), DM, Stroke (2), Vascular disease, Age 65-74, Sex - female
      • Score 1 - consider; ≥2 - DOAC/Warfarin needed
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63
Q

Types of anticoagulant

A

Heparins

  • LMWH (SC) - VTE prophylaxis BUT bad for renal function
  • UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring

DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)

Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions

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64
Q

PE - drug Tx?

A

Initial Tx:

  • DOAC (e.g. Apixaban) or unfractionated heparin (if bleeding risk, can be reversed easily)
  • Massive PE –> IV unfractionated heparin for hours before and after thrombolysis e.g. IV alteplase

Ongoing anticoagulation - DOAC/Warfarin

  • Provoked - 3 months (SICC)
  • Unprovoked - >6 months + cancer & thrombophilia testing
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65
Q

Hypertension BP targets? Mx?

A

BP targets:

  • <140/90
  • <150/95 if >80yrs

Drug treatment:

    1. a) <55yrs/DM –> ACEi (ramipril)/ANG-II receptor antagonist (Losartan)
    1. b) ≥55yrs/black –> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide)
    1. ACEi + CCB OR ACEi + thiazide diuretic
    1. ACEi + CCB + thiazide diuretic
    1. Add:
      * Spironolactone (or other diuretic)
      * Alpha-blocker
      * Beta-blocker
      * Specialist advice
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66
Q

T1DM/T2DM - drug Mx?

A

T1DM Mx: exogenous insulin to avoid DKA & long-term complications

  • BM targets - fasting BM:
    • Waking: 5-7mmol/litre
    • Before meals: 4-7mmol/litre
  • Insulin regimens:
    • 1st line - Basal-bolus regimen
      • Basal (background) - BD insulin detemir as basal insulin
      • Bolus (before meals) - analogue rapid-acting insulin e.g. insulin lispro
    • Other:
      • BD biphasic (premixed insulin, hypos common)
      • OD before bed long-acting (for T2DM)

T2DM Mx:

  • 1st line - Lifestyle changes - DESMOND course for T2DM, dietician input, self-BM monitoring (individual HbA1c target <6.5)
  • Medication:
    • 2nd - Metformin (SEs: LA - avoid if eGFR <30)
    • 3rd - ADD Sulphonylurea e.g. Gliclazide (SEs: hypoglycaemia, weight gain)
    • 4th - ADD other DM med:
      • Pioglitazone (SEs: hypoglycaemia, weight gain, oedema, fractures in elderly)
        • C/I in HF, bladder cancer
      • SGLT-2 inhibitor e.g. Empagliflozin (SEs: Hypoglycaemia, weight loss, UTI)
        • Not recommended in impaired renal funct
      • DPP-4 inhibitor e.g. Linagliptin (APPROVED FOR USE IN CKD, weight neutral)
      • GLP-1 analogues e.g. Exenatide/Liraglutide (SE: weight loss - useful if BMI >35; vomiting)
        • Not recommended in impaired renal funct
    • 5th - If on triple therapy & not providing control –> commence insulin
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68
Q

SGLT2 inhibitors S/E?

A

e.g. dapagliflozin

Increased yeast/UTIs, hypoglycaemia, weight loss

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69
Q

Pioglitazone S/E? C/Is?

A

hypoglycaemia, weight gain, fluid retention (oedema), assoc with bladder cancer, osteoporosis (elderly - fractures)

C/Is: HF, bladder cancer

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70
Q

Perioperative DM Mx?

A

Variable insulin infusion for 30-60 mins after starting SC insulin to avoid iatrogenic DKA

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71
Q

Sulphonylureas (oral) or insulin (sc) S/E?

A

Weight gain & hypoglycaemia

73
Q

Diabetic patient having surgery:

  • What to do if high HbA1c?
  • What to do if long surgical period (missing 2 meals)?
  • What to do if short surgical period if taking insulin/other diabetic meds?
  • What to do the day before admission and day after surgery?
A

If poorly controlled DM (HbA1c ≥69) or long starvation period (≥2 missed meals) –> variable rate insulin infusion + IV maintenance fluids (5% glucose in 0.45% saline)

If on insulin:

  • If using variable rate insulin infusion - stop all insulin until eating/drinking normally and has been 30mins since first post-op insulin dose
  • Basal (background insulin) always maintained to prevent ketosis - dose reduced by 20% to avoid hypoglycaemia
  • Bolus (before meals) avoided:
    • If AM surgery - omit morning & lunch dose
    • If PM surgery - omit lunch dose

If on diabetic medications:

  • Stop ALL if variable-rate insulin infusion used - apart from GLP-1, which can be maintained
  • Insulin & sulphonylureas (glipizide) - dose must be reduced as they lower BM –> hypoglycaemia
    • AM surgery - omit morning dose
    • PM surgery - omit morning and afternoon dose
  • Metformin, GLP-1 analogues (liraglutide), DPP-IV inhibitors (linagliptin), SGLT2 inhibitors (dapagliflozin) - rarely cause hypoglycaemia while fasting (only reduced if other concerns)
    • SGLT2 inhibitors - omit morning dose if AM/PM surgery

NOTE: take all as normal day before admission, take as normal day after surgery

74
Q

Correcting hyperglycaemia in DM:

  • How much does 1 unit of rapid-acting insulin reduce BM by?
  • How much to adjust insulin dose by at one time?
  • Target insulin dose?
A

ASK PATIENT - rule of thumb is 100/total daily dose (TDD)

  • E.g. TDS Actrapid 7 units + 18U lantus = 39U TDD –> 100/39 = 2.5
  • Generally it is roughly 3mmol/L

10%

Target glucose: 4-10 (aim for 7-8) - if on insulin:

  • Waking 5-7, otherwise 4-7
75
Q

DPP-4 - massive benefit in T2DM?

A

e.g. linagliptin

Approved for use in CKD

76
Q

Why use GLP-1 analogue for T2DM? Other SE? How is it given?

A

e.g. exenatide/liraglutide

Induces weight loss (good for BMI >35, >30 + comorb)

Vomiting

SC inj

77
Q

Osteoporosis Mx? Using bisphosphonates –> jaw pain & swelling?

A

0 to -2.5 DEXA: conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes

  • Repeat DEXA @2yrs
  • 1st line - Bisphosphonates PO (e.g. alendronic acid) –> if not tolerate can trial Denosumab/Raloxifene/Teriparatide
  • Vit D + Ca replacement (if inadequate sunlight/intake exposure)
  • Review Tx every 3-5yrs

NOTE:

  • If premature menopause –> discuss HRT
  • If on high-dose CS (≥7.5mg OD for ≥3 months) –> consider bisphosphonates for bone protection

Osteonecrosis of the jaw

78
Q

Benign prostatic hyperplasia (BPH) - drug Mx?

A

Mx:

  • Medical:
    • Alpha-blocker (relax sm muscle around prostatic urethra) e.g. tamsulosin
    • 5-alpha-reductase inhibitor (reduce conversion of testosterone –> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. finasteride
79
Q

AKI - drug Tx?

A

Mx:

  • Identify & Mx the cause
  • Hypovolaemic - IV fluid bolus
  • Hypervolaemic - if pul oedema –> loop diuretic (furosemide) + Na restriction
80
Q

Paeds - Bronchiolitis vs Croup - drug Mx?

A

Mx:

  • Bronchiolitis (from RSV, <1yr) - conservative (simple analgesia) + Palivizumab for prevention
  • Croup - oral dexamethasone 0.15mg/kg + neb O2 & adrenaline
81
Q

Long-term asthma Mx in kids?

A
  • <5yrs:
    • 1st line – SABA (reliever)
    • 2nd line – if atopic –> 8wk trial medium-dose ICS (preventer)
    • 3rd line
      • Steroid-unresponsive (recurrent Sx <4wks) –> low-dose ICS
      • Steroid-responsive (recurrent Sx >4wks) –> another 8wk course medium-dose ICS
    • 4th line – LTRA
    • 5th line – specialist advice
  • 5-16yrs:
    • 1st/2nd line - If SABA insufficient to control symptoms or bad enough symptoms at first presentation give SABA + ICS (morning and evening everyday 1 puff)
    • 3rd line - Leukotriene receptor antagonist (e.g., montelukast) –> block pro-inflam cytokines from arachidonic acid pathway (w/ COX)
    • 4th line - If LTRA not working add on LABA (either continue/discontinue LTRA)
    • 5th - If doesn’t work start maintenance & reliever therapy (MART) = 1 inhaler with ICS + LABA (morning and evening everyday) + used for relief as well instead of SABA inhaler
    • 6th line – OCS
    • 7th line – specialist advice
82
Q

GORD Mx in kids & adults?

A

Adults: standard-dose PPI ± H2 antagonist (Cimetidine)

83
Q

Constipation in kids Mx?

A
  • On exam feel for impacted stool
  • Dig into social aspects of constipation – look for precipitants e.g., diet, difficulty outside on home –> consider in conservative management
  • Osmotic laxative –> water moves into intestinal lumen from surrounding tissues
  • Stimulants –> contraction of intestines helping to pass bolus of faecal matter
84
Q

Urinary incontinence - types & drug Tx?

A

Stress-incontinence (leak on laugh/cough): pseudoephedrine (2nd - Duloxetine)

Urge-incontinence (preceded by the urge to pass urine): anticholinergic e.g. Oxybutynin (not if >80yrs), Tolterodine

Overactive bladder syndrome (urge but not incontinence - increased freq + nocturia): same as urge incontinence

85
Q

Fibroids & Endometriosis - drug Tx?

A

Fibroids:

  • Tranexamic acid - for haemorrhagia
  • NSAIDs (mefenamic acid) - for pain relief
  • OCP/marina coil - if don’t want pregnancy
  • Progestogens (norethisterone) for acute bleed

Endometriosis:

  • NSAIDs
  • Hormonal:
    • COCP/progestogen-only OCP, levonorgesterol-IUD (mirena coil), implant
    • GnRH agonist
86
Q

PCOS drug Tx?

A

COCP (or Marena coil)

Fertility: ovulation induction e.g. clomifene

87
Q

Menopause drug Tx? SEs?

A

HRT: see ‘sex hormones’ on medicines complete - search estradiol/estradiol with norethisterone

  • If hysterectomy –> oestrogen-only OD (estradiol)
  • Cyclical (have menses):
    • Regular - estradiol OD, progestogen (norethisterone) on last 14 days of cycle
    • Irregular - estradiol OD, norethisterone on month when have period
  • Continuous - estradiol & norethisterone OD after 1yr cyclical therapy/no withdrawal bleeding (established menopause)
  • Vaginal atrophy –> topical estradiol

SEs: breast cancer (combined), VTE risk (not patches)

  • Reduced risk of osteoporosis
88
Q

Contraception options?

89
Q

VTE in pregnancy Tx?

A

Conservative – compression stockings + elevation

LMWH throughout pregnancy + 3-months post-partum

90
Q

Post partum haemorrhage - drug Tx?

A

Medical: Syntocinon IV

91
Q

Pre-eclampsia drug Tx?

A

Control BP – oral Labetalol/Nifedipine (severe – IV labetalol/hydralazine)

Prevent seizures – IV Magnesium Sulfate

92
Q

How to treat hyperemesis gravidarum - drugs?

A

Conservative - ginger, pressure point

Medical:

  • If no volume depletion:
    • Doxylamine (vit B6) &/or pyridoxine (anti-histamine)
    • 2nd - metoclopramide
  • If volume depletion:
    • IV fluids
    • IV metoclopramide ± PPI (omeprazole)

Other:

  • Thiamine supplementation (B1, 1/wk) –> wernicke’s
  • Thromboprophylaxis (LMWH + stockings due to bed rest, lack of movement)
93
Q

Emergency contraceptives?

94
Q

Medical drug Tx for msicarriage?

A

misoprostol (vaginal pessary or oral)

95
Q

Medical abortion - drug tx?

A

<9wks - oral mifepristone, followed 24-48hrs by oral misoprostol

96
Q

Thrush (vaginal candidiasis) - drug Tx?

A

Local: clotrimazole pessary (e.g. clotrimazole 500mg PV stat)

  • If preg can only use local Tx

Oral:

  • Itraconazole 200mg PO BD (for 1 day)
  • Fluconazole 150mg PO stat
97
Q

Prescribing in pregnancy?

A

Antihypertensives

  • ACEi (not in pregnancy) - Ramipril
  • B-blockers (IUGR, bradycardia - possibly in pregnancy) - Atenolol, Labetalol (not known to be harmful except possibly in 1st trimester)
  • Ca-channel blockers - Nifedipine (fine in all trimesters, but possible tocolytic effect, avoid before week 20, only use if other options have failed)
  • Methyldopa (not known to be harmful during pregnancy) BUT often does not provide reasonable hypertensive control
  • Balanced approach (risk of foetus vs hypertension in mother):
    • Can control tocolytic effect by increasing oxytocin during labour
    • Typically Labetalol and Nifedipine are used

Alcohol

  • NOT DURING PREGNANCY (the odd drink very rarely is fine)

Anti-epileptic

  • Sodium Valproate = VERY BAD (teratogenic), currently thought to be fine in breast feeding
  • Examples can switch to —> Lamotrigine, Topiramate
98
Q

Meningitis, GCA, Migraine drug Mx?

A

Meningitis & encephalitis Mx:

  • Suspected in primary care - IM/IV Benzypenicillin
  • Secondary care - IV Ceftriaxone ± Amoxicillin (infants/>50yrs)
  • If could be encephalitis (seizure/behavioural) - IV Aciclovir​

GCA Mx: high-dose Prednisolone ± alendronic acid (if long-term steroids)​

Migraine Mx:

  • Acute - simple analgesia + Triptans (take as soon as Sx start)
  • Prevent - trigger avoidance + propranolol/ topiramate (anticonvulsant) /amitriptytline (TCA)
99
Q

Ischaemic Stroke Mx?

A

Ischaemic:

  • Immediate:
    • Aspirin 300mg OD + STOP anticoagulants (high risk of haemorrhagic transformation in first 2wks)
    • <4.5hrs since Sx onset: thrombolysis (Alteplase = tPA)
    • >4.5hrs since Sx onset: conservative Mx
  • After 2wks:
    • STOP aspirin –> start clopidogrel 75mg OD + consider anticoagulation (e.g. if AF) - DOAC/Warfarin
100
Q

Parkinson’s drug Mx?

A

Mx: problem = lack of dopamine in substantia nigra –> aim of Tx is to increase dopamine here

  • Dopamine agonist (cross BBB) –> Ropinirole /Pramipexole /Apomorphine
  • ‘L-DOPA AND peripheral DOPA-decarboxylase enzyme (Carbidopa)’ –> Co-Beneldopa (Madopar)/Co-Careldopa (Sinemet)
103
Q

Epilepsy - drug Mx by type?

Status epileptics drug Mx?

A

Types:

  • Generalised (whole brain):
    • Tonic-clonic, Tonic, Atonic, Myoclonic –> Tx: Na Valproate (AVOID in girls/women of childbearing age)
    • Absence –> Tx: Ethosuximide/Na Valproate
  • Focal - aware (conscious) OR impaired awareness (impaired consciousness)
    • Tx: Lamotrigine

Status epilepticus = >5mins/repeated seizures without full recovery in between

  • 1st - IV lorazepam 4mg –> repeat
  • 2nd - phenytoin infusion
  • 3rd - general anaesthesia
  • If no IV access –> rectal diazepam/buccal midazolam
105
Q

Alzheimer’s drug Mx?

A

Tx: Acetylcholinesterase inhibitors (Donepezil, galantamine, rivastigmine)/NMDA receptor antagonists (Memantine)

106
Q

Bell’s palsy - drug Mx?

A

Mx:

  • Pred (if <72hrs Sx onset)
  • Severe palsy/complete paralysis –> concurrent antiviral therapy (aciclovir), surgical decompression
107
Q

Impetigo - drug Tx?

A

systemic antibiotic e.g. erythromycin, flucloxacillin

108
Q

Pneumonia - drug Tx?

A

CAP:

  • Typical (S. pneumo, H. influenzae) –> Amox/Co-Amox
  • Atypical (Legionella, Mycoplasma, Chlamydia) –> Clari
  • NOTE: if not sure often given Co-Amox + Clari

HAP - pneumonia arising >48hrs after admission to hospital (S. pneumo, S. aureus, P. aeruginosa) –> Taxocin (pseudomonal cover)

109
Q

Hyponatremia - Approach? What happens if you correct Na too fast?

A

Fluid status:

  • HYPOvolaemic (dehydrated) - WASTING (diarrhoea/vomiting, diuretics) –> IV fluids
  • EUvolaemic (normal) - ENDOCRINE (SIADH, hypothyroidism, Addison’s) –> fluid restrict
  • HYPERvolaemic (fluid overload) - FAILURE (liver, renal, heart) –> fluid restrict + Tx underlying cause

Na corrected too fast (>10) = osmotic demyelination syndrome (central pontine myelinolysis) –> pseudo-bulbar palsy, paraparesis, locked-in syndrome

110
Q

Hyperkalaemia Tx drug Tx?

A

Hyperkalaemia Tx:

  • Protect heart - IV 10-30ml 10% Ca Gluconate (repeat /15m, x5 MAX)
  • Reduce K+:
    • 1st line - 10U Actrapid (insulin > drive K into cells) AND 100mL 20% glucose (to prevent hypo)
    • 2nd line - 5mg Salbutamol NEB (b-agonist)
  • Ix cause: drug chart, U&E (kidney funct), short SynACTHen test (Addison’s)
113
Q

Thyroid disease - hypo/hyper drug Tx?

A

Hypothyroidism Mx:

  • Thyroid replacement therapy (levothyroxine)
  • Myxoedema coma - A-E & active warming, T3 slow IV, hydrocortisone IV

Hyperthyroidism Mx:

  • Medical:
    • Sx relief – B-blockers
    • Antithyroid meds - Carbimazole (or propylthiouracil)
      • SEs: rashes, agranulocytosis - monitor​y
  • Thyroid storm: acute state of shock, pyrexia, confusion, vomiting
    • Propylthiouracil 600mg –> 200mg QDS
114
Q

Ca - hypo/hyper drug Tx?

A

HYPERcalcemia ​

  • Sx:
    • Stones - urinary tract calculi
    • Bones - fractures
    • (Abdo) moans - dyspepsia
    • Thrones - polyuria, constipation
    • (Psych) overtones - depression, psychosis
  • Mx:
    • IMMEDIATE = aggressive IV 0.9% fluid resus (4-6L over 24krs), repeat Ca

​HYPOcalcaemia

  • Presentation:
    • Peri-oral numbness, digital paraesthesia, dermatitis
    • +ve Trousseau’s (BP cuff 20 over SBP for 3mins –> salt bae hand), Chovstek signs (tap over the masseter muscle in the inferior pre-auricular area)
    • Laryngospasm (wheeze, dysphagia, muscle cramps)
    • Confusion, seizures, prolonged QT
  • Mx: PO/IV replacement of Ca
115
Q

Drug Mx of obesity?

A

Medical (none proven to provide sustainable weight loss)

  • Orlistat (gut lipase inhibitor, SEs: profound flatus, diarrhoea)
116
Q

Osteoarthritis - drug Tx?

A

Medical – analgesia (paracetamol/NSAID), IA CS injection

  • Paracetamol –> topical NSAIDs –> oral NSAIDs
118
Q

Gout - drug Mx?

A

Presentation: 1st MTP joint, monoarticular (can be poly)

Mx:

  • Acute:
    • NSAIDs, Colchicine
    • Oral Pred (5 days), steroid joint injection
  • Chronic:
    • Xanthine oxidase inhibitor e.g. allopurinol
119
Q

Hypercholesterolaemia - drug Tx?

A

1st - statins e.g. atorvostatin

2nd - lipid-regulating drug e.g. ezetimibe

120
Q

Conjunctivitis - breakdown & drug Tx?

A

Mx bacterial: topical azithromycin

  • Viral/allergic - topical antihistamine e.g. epinastine
122
Q

Acute angle-closure glaucoma - drug Tx?

A

Presentation: blurring of vision, painful red eye, headache, N&V

Mx: 1st line:

  • Carbonic anhydrase inhibitors (acetazolamide) AND/or
  • Topical beta-blockers (timolol) AND/or
  • Topical alpha-2 agonists (brimonidine)
123
Q

Sickle cell crisis - Mx?

A

ACUTE (PAINFUL CRISES)

  • Oxygen
  • IV Fluids
  • Strong analgesia (IV opiates)
  • Antibiotics
  • Cross match blood
  • Give transfusion if Hb or reticulocytes fall sharply
124
Q

Polymyalgia rheumatica - drug Tx?

A

Presentation: muscle aches and joint stiffness

  • Difficult to rise from seated/prone position
  • Shoulder/hip stiffness & bursitis
  • muscle tenderness & oligoarthritis

Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates)

  • Other: methotrexate + folic acid
125
Q

Analgesic ladder

A

Oxycodone > morphine if renal impairment

Do not give NSAIDs in asthma/renal impairment/elderly/pregnant

Neuropathic pain does not respond to opioids

127
Q

Pain assoc w/ renal colic responds well to?

A

Responds well to PR NSAIDs (diclofenac)

128
Q

Tx for trigeminal neuralgia?

A

Carbamazepine 1st line for neuropathic pain

129
Q

Diabetic painful neuropathy Mx?

A

duloxetine

130
Q

Anaemia - drug Mx?

A

Blood transfusion threshold: Hb <70 or <80 AND ACS

  • Other options: Fe infusion, ferrous fumarate
131
Q

What opioids can I use if renal problem?

A

Fentanyl, Buprenorphine

Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)

132
Q

Anticipatory meds - 4 to give if palliative?

A

Anxiety/distress: Midazolam 2.5-5mg SC 1-2hrly PRN

Secretions/colic: Glycopyrronium 0.2-0.4mg SC QDS PRN

Nausea & vomiting: Haloperidol 0.5-1.5mg SC BD PRN (max 5mg/24hrs)

  • Could give Cyclizine 50mg SC TDS PRN

Pain: Morphine 2.5-5mg SC 1-2hrly PRN (or Oxycodone 1.25-2.5mg)

133
Q

Best palliative medicine for secretions/colic?

A

Glycopyrronium 0.2-0.4mg SC QDS PRN

134
Q

Some antiemetics? When to use each one?

A

PHOMO (C not O)

Prochlorperazine for vestibular causes

Haloperidol for IC causes (raised ICP/tumour)/palliative

Ondansetron for chemo-induced nausea

Metoclopramide for GI causes

Cyclizine if risk of EPSEs/QT prolongation

135
Q

STI - types? Mx?

A

SEARCH “Genital System Infections”

  • Chlamydia (Chlamydia trachomatis) – obligate intracellular G-ve (can’t be cultured on agar)
    • Mx: Azith 1g STAT/Doxy 100mg BD 7 days
  • Gonorrhoea (Neisseria gonorrhoeae) – obligate intracellular G-ve diplococcus
    • Mx: ceftriaxone 250mg IM STAT
  • Syphilis (Treponema pallidum) – obligate G-ve spirochaete
    • Mx: IM Ben Pen STAT
  • Bacterial vaginosis - fish-like odor, thin/off-white discharge, clue cells, mild irritation
    • Mx: Metro (top/oral) OR clindamycin (top)
  • Trichomoniasis (parasite) - musty odor, pale green discharge, strawberry cervix, motile flagellated protozoa, dysuria/tenderness/itchy
    • Mx: Metro (oral)
136
Q

Constipation drug Tx?

A

1st - Bulk laxative e.g. fybogel (ispghula husk)/methylcellulose

2nd - Osmotic laxative e.g. lactulose/movicol/polyethylene glycol

3rd - Stimulant laxative e.g. Senna

137
Q

HIV drug Tx?

A

ART first line:

  • 2 NRTIs (tenofovir & abacavir)
  • AND NNRTI (Efavirenz)/PI (Ritonavir)/Integrase inhibitor (Raltegravir)

Pneumocystis pneumonia (PCP) –> co-trimoxazole

138
Q

TB Tx?

A

Rifampicin & Isoniazid (6 months), Pyrazinamide & Ethambutol (2 months)

139
Q

Acne vulgaris - drug Tx?

A
  • Single topical therapy: topical retinoid or benzoyl peroxide
  • Topical combination therapy (choose 2 or more): topical retinoid, benzoyl peroxide, topical antibiotic
  • Add oral antibiotics: tetracycline, macrolide, trimethoprim
  • (Sometimes COCP as alternative in women)
  • Oral isotretinoin
140
Q

Eczema - drug Tx?

A

Emolients

MILD: hydrocortisone 1%

MODERATE: betamethasone valerate 0.025% OR clobetasone butyrate 0.05%

SEVERE: betamethasone valerate 0.1% –> oral corticosteroids

Infected eczema –> PO Flucloxacillin

141
Q

Seborrhoeic dermatitis Tx?

A

Infant - topical imidazole cream (Clotrimazole 1%)

Adolescent - ketoconazole 2%

142
Q

Allergic rhinitis - drug Tx?

A

Intranasal CS e.g. betametasone nasal

Oral AH e.g. citirizine

143
Q

When do you need to do daily INR monitoring on Warfarin?

A

WARFOAC:

  • Warfarin needs daily INR monitoring if on:
  • Abx
  • Regular tramadol
  • Fluconazole
  • Omeprazole
  • Amiodarone
  • Corticosteroids (high dose)
144
Q

Fluids:

  • Normal maintenance requirements for the patient if NBM (H20, Na, K, UO)?
  • Maintenance fluids
  • Resus fluids
A

Normal requirements if NBM:

  • H20 - 25-30ml/kg/day (cardiac disease is 20-25)
  • Na/K/Cl - 1mmol/kg/day
  • Glucose - 50-100g/day (prevent ketosis)
  • UO should be >0.5ml/kg/hr

Maintenance fluids - traditional fluid regimen of ‘1 salty + 2 sweet’

  • 1L saline 0.9% + 20mmol KCl (over 6-8hrs)
    • NOTE: contains 154mmol Na/Cl in 1L bag
  • 2x 1L dextrose 5% + 20mmol KCl (over 6-8hrs)
    • NOTE: on medicine complete written as glucose 5%/potassium chloride 0.15% (0.3% if want 40mmol KCL)
  • NOTE: surgeons often prescribe Hartmann’s instead of NaCl as isotonic –> less likely to cause hyponatremia (above regimen provides too much H2O & too much Na)

Resus fluids - 500ml fluid bolus 0.9% NaCl over 15-20 minutes (250ml if HF)

145
Q

Septic shock definition? Neutropenic sepsis criteria & abx Tx?

A

Septic shock = sepsis + haemodynamic instability

Neutropenic sepsis:

  • Neutrophils <0.5
  • Temp >38 degrees
  • Tx = Tazocin
146
Q

How to determine different causes of shock & Tx?

147
Q

What is sepsis 6?

A

3 in, 3 out

All within 1hr

148
Q

Mx of RA?

A
  • Create an end target e.g., remission
  • 1st - Monotherapy with conventional DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved ± NSAIDs - Sx Mx (ibuprofen/naproxen)
  • Target met?
    • Yes = keep drug regime + lifestyle changes
    • No = titrate cDMARD/trial alternative cDMARD ± dual therapy
  • Target met?
    • Yes = keep drug regime + lifestyle changes
    • No = biological agents if DAS28 score >5.1 (severe burden of disease)
149
Q

Best abx for cellulitis?

A

Fluclox (clari if pen allergy)

150
Q

Mild tonsilitis scoring & abx?

A

CENTOR/FeverPAIN score

Tx: Phenoxymethylpenicillin (Clari if pen allergic)

151
Q

Tx for dog/cat bite?

A

Prophylaxis & treated = Co-amoxiclav

152
Q

Dendritic ulcer in the eye - Tx?

A

Antiviral ointment e.g. aciclovir

If necrotising stromal keratitis –> Steroid eyedrops e.g. dexamethasone (only by specialist)

153
Q

Otitis medial Abx?

A

Amoxicillin

154
Q

Pityriasis Versicolor - skin scrapings finding? Tx?

A

Presentation: chest/back/neck/proximal arms

  • Dyspigmentation
  • Macules/patches
  • Fine overlying scale

Skin scrapings: short hyphae and budding yeast with spaghetti-and-meatballs appearance

Tx: anti-fungal e.g. ketoconazole 2% shampoo

155
Q

VTE prophylaxis?

A

LMWH e.g. dalteparin & TED stockings

156
Q

Hyper/hypocalcaemia Mx?

A

HYPERcalcemia ​

  • Sx:
    • Stones - urinary tract calculi
    • Bones - fractures
    • (Abdo) moans - dyspepsia
    • Thrones - polyuria, constipation
    • (Psych) overtones - depression, psychosis
  • Mx:
    • IMMEDIATE = aggressive IV 0.9% fluid resus (4-6L over 24krs), repeat Ca
    • Tx underlying cause:
      • Parathyroid adenoma - minimally invasive surgery (subtotal/total parathyroidectomy)
      • Malig - Pamidronate (inhibit osteoclast activity), slow infusion
      • Other:
        • If bone mets –> bisphosphonates
        • If renal failure –> Cinacalcet (reduce PTH)

HYPOcalcaemia

  • Presentation:
    • Peri-oral numbness, digital paraesthesia, dermatitis
    • +ve Trousseau’s (BP cuff 20 over SBP for 3mins –> salt bae hand), Chovstek signs (tap over the masseter muscle in the inferior pre-auricular area)
    • Laryngospasm (wheeze, dysphagia, muscle cramps)
    • Confusion, seizures, prolonged QT
  • Mx: PO/IV replacement of Ca
157
Q

Panic attacks with palpations - Tx?

A

Propranolol

If GAD Sx –> SSRI

158
Q

Lyme disease Tx?

A

Oral doxycycline for 21 days

If CNS involved use IV ceftriaxone instead

159
Q

Torsade de Pointes (TdP) - Tx?

A

Broad-complex irregular tachycardia where the size and shape of the QRS varies complex to complex within any given lead (polymorphic)

  • Increased QT interval increases the risk e.g. drugs (clari, amiodarone)

Magnesium sulfate IV 2g over 10 minutes

160
Q

Addison’s & Conn’s - drug Tx?

A

Addison’s disease - adrenal insufficiency

  • Presentation: Anorexia/weight loss, fatigue/weakness, postural dizziness, reduced libido, sweating
    • N&V, diarrhoea, salt craving
    • Signs: hyperpigmentation in skin creases/lip/mouth, vitiligo, sparse axillary/pubic hair
  • Ix: short synACTHen test
  • Mx: IV fluids –> IV hydrocortisone ± fludrocortisone (if primary adrenal lesion)

Conn’s/bilateral adrenal hyperplasia - high aldosterone

  • Ix: aldosterone-renin ratio (ARR) - Conn’s has high aldosterone, low renin; BAH has both high
  • Mx: spironolactone
161
Q

Mastitis Tx?

A

If Sx have not improved for 24hrs while continuing to express milk –> Flucloxacillin

162
Q

Refeeding syndrome - Tx?

A

Low K, Mg, PO4, Ca, Na + fluid overload

  • Carefully reintroduce nutritional support
  • Correct electrolyte abnormalities
163
Q

PaO2 (Partial Pressure of Oxygen) normal range?

A

Normal: ≥10 on room air

On Oxygen: PaO2 (kPa) should be 10 less than FiO2 (level of oxygen they are on %)

164
Q

Oxygen therapy principles

A

Oxygen from wall = 100%

Peak inspiratory flow - the maximum rate of drawing in O2 normally is 20L/min (not normally measured unless ITU)

O2 therapy goal is increasing conc grad between alveoli and blood - done by increasing FiO2 (fraction of inspired O2)

Devices types:

  • Variable (can’t guarantee FiO2, depends on PIF):
    • Nasal cannula 1-4L
    • Hudson mask 5-10L
    • Non-rebreather mask 15L
  • Fixed: venturi mask (useful if COPD as need to know exactly how much O2 giving) - 24%, 28%, 35%, 40%, 60%

NOTE: If PIF increases (breathing harder) –> FiO2 decreases so more device O2 is required

High-flow nasal oxygen therapy - humidifies + warms O2 = well-tolerated –> very high flow rate can be achieved - finely controlled FiO2

165
Q

Trimethoprim combined with what steroid-sparing agent is a bad idea and why?

A

Methotrexate –> BM suppression & pancytopenia

166
Q

Hyperosmolar Hyperglycaemic State

  • What does insulin do? Pathophysiology of HHS?
  • HHS criteria? HHS Mx? HHS Mx Targets?
A

Insulin:

  • High level of insulin –> reduces serum BM (pushes into surrounding tissues & hepatic glucose store)
  • Low level of insulin –> switches off ketone production

Pathophysiology:

  • HHS = complication of T2DM
  • In HHS have enough insulin to switch of ketone production but not enough to reduce BM lvls
  • High glucose - osmotically active –> polyuria –> dehydration

HHS criteria:

  • Hypovolaemia
  • Glucose >30mmol/L
  • NO ketonaemia
  • Serum osmolality >320mOsmol/kg

Mx: REHYDRATE = IV 0.9% NaCl (3-6L by 12hrs, deficit 110-220mL/kg)

  • Targets:
    • Reduce Na by less than 10mmol/L/day (otherwise risk osmotic demyelination syndrome)
    • Reduce BM by over 5mmol/L/hr
    • NOTE: if targets not met by 0.9% saline –> 0.45% instead
  • If fluid alone are not enough –> 0.05 units/kg/hr fixed-rate insulin infusion
167
Q

What drugs to stop before surgery?

A

Search - Surgery and long-term medication

Anticoagulants/Platelets (several days before surgery)

  • Warfarin
  • Heparins - dalteparin
  • Antiplatelets - aspirin, clopidogrel, ticlopidine, dipyridamole
  • NSAIDs
168
Q

Alcohol withdrawal management?

A
  1. Chlordiazepoxide (decreasing regimen + PRN) - prevent alcohol withdrawal Sx (anxiety, shakes etc.) + CIWA scoring (dose increased inf CIWA score increases)
  2. Pabrinex (thiamine, B1) - prevent Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion)
  3. Bloods - coagulation (injury, bleeds), LFTs
169
Q

Taking Warfarin and due to have surgery - what to do?

What to do if INR >1.5 the day before surgery?

A

Stop Warfarin 5 days before

Give Vit K (phytomenadione) 1-5mg PO

170
Q

What to monitor for effective Tx of HF with furosemide?

What to monitor for effective Tx of HF with ACEi?

A

Furosemide:

  • 2 days - Weight
  • Longer - ejection fraction

ACEi: improved exercise tolerance

171
Q

What to search for Warfarin dose adjustments?

What to search for Heparin dose adjustments?

A

Oral anticoagulants

Parenteral anticoagulants

172
Q

Antipsychotic drug SEs & Tx? What is a similar condition in anti-depressant consumption?

A

Acute dystonia - onset in hrs, spasms/muscle contractions (involuntary, painful, sustained) e.g. torticollis, oculogyric crisis (twists up, can’t look down)

  • Tx: anticholinergic e.g. procyclidine IM/IV

Akathisia - onset in hrs-wks, subjective psychomotor restlessness

  • Tx: propranolol ± benzo (cyproheptadine)

Parkinsonism - onset days-wks, triad: resting tremor, bradykinesia, rigidity

  • Tx: anticholinergic e.g. procyclidine IM/IV

Tardive dyskinesia - onset months-yrs, rhythmic involuntary mov of mouth, face, limbs, trunk (e.g. grimace, chewing, sucking mov)

  • Tx: stop antipsychotic/reduce dose, can try tetrabenazine

Neuroleptic malignant syndrome (NMS) - onset days-wks, life-threatening, cog changes, fever, rigidity & bradyreflexia, autonomic dysfunction

  • Raised CK on bloods
  • Mx: stop antipsychotic, ITU, bromocriptine
  • NOTE: Serotonin syndrome has a similar presentation but acute (24hrs) & hyperreflexia, tremor, clonus, Tx with supportive care & benzo (cyproheptadine)
173
Q

Treatment of neuropathic/nerve compression pain?

A

Amitryptiline

(other 1st line options - pregabalin/gabapentin/duloxetine)

174
Q

Drugs associated with hyperkalaemia?

A

K ABCD HTN:

  • K+ sparing diuretics
  • ACEi/ARB, B-blockers (if renal dusfunct/insulin def), Calcineurin inh (Cyclosporine, Tacrolimus), Digoxin overdose
  • Heparins, Trimethoprim, NSAIDs
175
Q

What drugs can cause hyperglycaemia?

A

β-blockers, thiazide diuretics, corticosteroids (e.g. pred)

STuD PRANC AB

  • STeroids (CS, OCP), Diuretics (thiazides, loop)
  • PRotease inhibitors (end in ‘vir’ e.g. Ritonavir), ANti-psychotics/epileptics (e.g. phenytoin), Calcineurin inhibitors (Cyclosporine/Tacrolimus)
  • Adrenaline, Beta-blockers (don’t cause hyperglycaemia but delay recovery in T1DM & blunt Sx perception)
176
Q

Drugs commonly causing oedema e.g. ankle swelling?

A

CCB e.g. amlodipine

NSAIDs e.g. naproxen

Pioglitazone (DM drug)

Hormones e.g. CS (pred), oestrogen, progesterone, testosterone

Beta-blockers

177
Q

What should be checked before starting azathioprine?

A

Thiopurine Methyltransferase (TPMT) - low levels of this enzyme require a lowered dose of azathioprine

178
Q

Drugs causing urinary retention

A

Opioids, Benzos, Anticholinergics

NSAIDs, CCB

GA, alpha-adrenoceptor antagonists

Alcohol

PSA Exam (2 decks)

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