PSA Flashcards
1
Q
Which drugs should be stopped before surgery?
A
I LACK OP
Insulin Lithium Anticoagulants/antiplatelets COCP/HRT K-sparing diuretics Oral hypoglycaemics Perindopril and other ACE-inhibitors
2
Q
Which drugs should be increased in surgery?
A
Steroids - think sick day rules
3
Q
What are the common enzyme inducers?
A
PC BRAS - these decrease drug concentration
Phenytoin, Carbamazepine Barbiturates Rifampicin Alcohol (chronic excess) Sulphonylureas
4
Q
What are the common enzyme inhibitors?
A
AODEVICES - these increase drug concentration
Allopurinol Omeprazole Disulfiram Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute) Sulphonamides
5
Q
What are the side effects of steroids?
A
STEROIDS
Stomach ulcers Thin skin Edema Right and left heart failure Osteoporosis Infection Diabetes cushings Syndrome
6
Q
What are the CIs for NSAIDS?
A
NSAID
No urine (renal/AKI) Systolic dysfunction Asthma Indigestion Dyscrasia (clotting)
7
Q
What are the two options of antiemetics?
A
- Cyclizine
2. Metoclopramide
8
Q
What are the indications and contraindications for metoclopramide as an antiemetic?
A
Indications - nausea in heart failure
CI - parkinsons disease, young women (it is a dopamine antagonist and carries a risk of dyskinesia in this age group)
9
Q
What fluids should be given in hypernatremic/hypoglycaemic patients?
A
5% dextrose
10
Q
What fluids should be given in a patient with ascites?
A
Human-albumin solution (HAS) - this maintains osmotic pressure
11
Q
What fluids should be given if shocked with sBP <90?
A
Gelofusine (colloid) - maintains BP due to high osmotic content
12
Q
What fluids should be given in a patient shocked from bleeding?
A
Blood transfusion but colloid first if no blood available
13
Q
Before giving replacement fluids what should be assessed and how do you respond to this?
A
HR, BP, urine output
If tachycardic/hypotensive - give 500ml bolus stat immediately then reassess
If oliguric only - give 1L over 2-4h then reassess
14
Q
What volume of replacement fluids are given in heart failure?
A
250ml
15
Q
What is the max REPLACEMENT fluid prescription in one day?
A
2L
16
Q
What is the max MAINTENANCE fluid prescription in one day?
A
3L in adults (8hrly bags)
2L in elderly (12hrly bags)
17
Q
With a normal potassium level, how much kCl do patients require a day?
A
1mmol/kg/day
do not give at more than 10mmol/hour
18
Q
When giving fluids, what must you check?
A
- U&E
- Ensure not fluid overloaded
- Ensure bladder not palpable (indicates obstruction)
19
Q
Recent ischaemic stroke - heparin or no heparin?
A
NO HEPARIN - this should be for 2 months!
20
Q
What do most patients receive in hospital as thromboprophylaxis?
A
Dalteparin 5000 units daily SC
21
Q
Which diuretics cause hypokalemia?
A
Loop and thiazide diuretics
22
Q
Name some side effects of ACE inhibitors?
A
- Dry cough
- Hyperkalemia
- Dizziness
- Headache
- Weakness
23
Q
Why should methotrexate and trimethoprim never be given together?
A
Both folate antagonists - risk of pancytopenia, neutropenic sepsis, bone marrow toxicity
24
Q
Septic patient - methotrexate?
A
Stop methotrexate until you are sure whether it is neutropenic sepsis - IF IN DOUBT WITHOLD
25
TRUE OR FALSE - all diuretics can cause hyponatremia?
True - they can also cause hypernatremia if they contribute to dehydration.
26
TRUE OR FALSE - peripheral oedema is a side effect of calcium channel blockers?
True - think drug induced if recently started on amlodipine or verapamil
27
Why should verapamil and beta blockers not be prescribed together?
Risk of bradycardia and hypotension
28
Why is metoclopramide contraindicated in patients with PD?
Dopamine antagonist - crosses the BBB to act on central dopamine receptors in
29
What drugs cause hyperkalemia?
- ACE inhibitors
- Potassium sparing diuretics
- Spironolactone
- Angiotensin receptor blockers (losartan)
- Tacrolimus
- Dalteparin and all heparins!
30
Why should ibuprofen be stopped in AKI?
Inhibits prostaglandin synthesis - reduces renal artery diameter - reduces kidney perfusion and function
31
Why should ACE inhibitors be stopped in AKI?
Reduce angiotensin-II production - decrease in glomerular filtration when blood flood is reduced
32
Why should NSAIDS be avoided in asthma?
NSAIDs can cause bronchoconstriction in asthmatics and should be avoided unless strictly necessary
NB - if you have to use one use aspirin
33
If a patient on methotrexate has sepsis what action should be taken?
- Withhold methotrexate until neutropenic sepsis can be exclude
IF IN DOUBT WITHHOLD
34
Which electrolyte abnormalities can furosemide cause?
- Hyponatremia
| - Hypokalaemia
35
What drug class is contraindicated in asthmatics?
Beta-blockers - can trigger exacerbation of asthma
36
How should gentamicin be monitored?
Take blood sample 1 hour after administration (peak dose) and just before the next dose (trough)
37
What is the therapeutic range of lithium?
0.4-1.0 (toxicity is >1.5)
38
Which drugs worsen seizure control in patients with epilepsy?
- alcohol, cocaine, amphetamines
- ciprofloxacin, levofloxacin
- aminophylline, theophylline
- bupropion
- methylphenidate (used in ADHD)
- mefenamic acid
Also bear in mind drugs that interact with P450
39
How long after an acute stroke should enoxaparin be restarted?
2 months
40
How is insulin administered?
All insulin is S/C except for sliding scales using short-acting insulin (eg. act rapid, novorapid) which are given by IV infusion
41
What causes microcytic anaemia?
Iron deficiency
Thalassaemia
Sideroblastic anaemia
42
What causes normocytic anaemia?
Chronic disease
Acute blood loss
Haemolytic anaemia
Chronic renal failure
43
What causes macrocytic anaemia?
```
B12/folate deficiency
Excess alcohol
Liver disease
Hyothyroidism
Myeloproliferative, myelodysplastic, multiple myeloma
```
44
What are the causes of hyponatreamia?
HYPOVOLAEMIC - fluid loss, addison's, diuretics
EUVOLAEMIC - SIADH, hypothyroidism
HYPERVOLAEMIC - heart/renal/liver/thyroid/nutritional failure
45
What are the causes of hypernatremia?
Dehydration
Drips
Drugs (sodium tablets)
Diabetes insipidus
46
What are the causes of hypokalaemia?
```
DIRE
Drugs (loop, thiazide diuretics)
Inadequate intake or intestinal loss (D&V)
Renal tubular acidosis
Endocrine (Cushings/Conns)
```
47
What are the causes of hyperkalaemia?
```
DREAD
Drugs (spironolactone, ARBs eg losartan, ace inhibitors)
Renal failure
Endocrine (Addisons)
Artefact
DKA
```
48
Which drugs can cause neutropenia?
Carbimazole
| Clozapine
49
Which drugs may cause thrombocytopenia (low platelets)?
Penicillamine (used in RA treatment)
| Heparin
50
Raised urea
Normal creatinine
Not dehydrated
Low haemoglobin
Diagnosis?
Upper GI bleed
51
What can raised urea indicate?
Upper GI bleed
| AKI
52
Which antibiotics are nephrotoxic and can precipitate AKI?
Gentamicin
Vancomycin
Tetracycline (eg doxycycline)
53
What causes a raised ALKPHOS?
```
Any fracture
Liver damage
K (kancer)
Pagets disease of bone and pregnancy
Hyperparathyroidism
Osteomalacia
Surgery
```
54
Which drugs cause cholestasis and subsequent high bilirubin and high ALP?
```
Flucloxacillin
Coamoxiclav
Nitrofurantoin
Steroids
Sulphonylureas
```
55
What ECG changes can digoxin cause?
Depressed ST segment
56
Which drugs have a borrow therapeutic index and therefore require monitoring?
```
Digoxin
Theophylline
Lithium
Phenytoin
Gentamicin
Vancomycin
```
57
What are the signs of digoxin toxicity?
Confusion, nausea, visual halos, arrhythmias
58
What are the signs of lithium toxicity?
Early: tremor
Intermediate: tiredness
Late: arrhythmias, seizures, coma, renal failure, diabetes inspires
59
What are the signs of phenytoin toxicity?
Gum hypertrophy, ataxia, nystagmus, peripheral neuropathy, teratogenicity
60
What are the signs of gentamicin toxicity?
Ototoxicity, nephrotoxicity
61
What are the signs of vancomycin toxicity?
Ototoxicity, nephrotoxicity
62
How should gentamicin be monitored?
Monitor 1 hour after dose (peak) and just before next dose (trough)
If peak too high (>10), reduce dose
If trough too high (>1), increase dose interval
63
What dose of gentamicin do patients usually receive?
```
Most patients - 5-7mg/kg od
Renal failure (severe)/endocarditis - divided daily dosing (1mg/kg) either 12 hourly or 8 hourly
```
64
How are nomograms used in gentamicin monitoring?
Used to determine whether level is too high
1. Plot blood conc on y axis
2. Plot time between starting last infusion and taking blood on x axis
If resultant point falls within 24h continue at same dose
If point falls in 36h area, change to 36hourly dosing
If point falls in 48h area, change to 48hourly dosing
If point falls above 48h area, repeat gentamicin level and only re-dose when conc <1mg/L
65
What happens in paracetamol OD?
1. Depletion of glutathione stores (antioxidant that metabolises paracetamol)
2. Accumulation of toxic metabolite NAPQI
3. Acute liver damage
66
What is the target INR for patients on warfarin?
2. 5
| 3. 5 if metallic valves, recurrent VTE
67
How should a major bleed be managed in pt on warfarin?
- Stop warfarin
- Give 5-10mg IV vit K
- Give beriplex
68
Management of minor bleed, INR >8?
- Stop warfarin
- Give 1-3mg IV vit K
- Repeat if necessary
- Restart warfarin when INR<5
69
Management of no bleed, INR>8?
- Stop warfarin
- Give 1-5mg ORAL vit K
- Repeat if necessary
- Restart warfarin when INR<5
70
Management of no bleed, INR 5-8?
- Stop warfarin for 2 days
| - Reduce dose
71
Management of no bleed, INR<6?
- Reduce warfarin dose
72
Why should ibuprofen be stopped in AKI?
Inhibits prostaglandins, this reduces blood flow to the kidney
73
What antibiotic combo is usually given for neutropenic sepsis?
IV Tazocin + IV Gentatmicin
74
What are the sick day rules for patients with Addisons Disease?
Increase steroids to provide adequate cortisol for the stress response
75
TRUE OR FALSE - Whilst on salbutamol neb you should stop the inhaled salbutamol
TRUE
76
How should furosemide be administered in an acute setting?
Intravenously
77
What drug is indicated for hypertension in over 55 or afro caribbean patients?
CCB - amlodipine
| contraindicated in HF
78
What additional med should all patients on opiates be prescribed?
Laxative
79
When increasing an opioid dose, how much should you increase the dose?
30-50% (NEVER MORE)
80
What meds are used to treat metastatic bone pain?
Strong opioids, bisphosphonates, denosumab
81
How do you convert oral morphine to subcutaneous morphine?
Divide by 2
82
Which prophylactic antibiotic is given to contacts of meningitic patients?
ORAL Ciprofloxacin/Rifampicin
Prophylaxis needs to be offered to household and close contacts of patients affected with meningococcal meningitis. Prophylaxis should also be offered to people who been exposed to respiratory secretion, regardless of the closeness of contact.
People who have been exposed to a patient with confirmed bacterial meningitis should be given prophylactic antibiotics if they have close contact within the 7 days before onset
83
How is anaphylaxis managed?
1. IM Adrenaline
2. High flow Oxygen and IV fluids
3. IV Chlorphenamine (antihistamine)
4. IV Hydrocortisone
84
Why should beta blockers never be prescribe with verapamil?
Risk of life threatening bradycardia
85
In which instances is gradual withdrawal of steroids required?
1. Received more than 40mg prednisolone daily for more than one week
2. Received more than 3 weeks treatment
3. Recently received repeated courses
86
In paracetamol OD, when should NAC be given?
1. There is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
2. The plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
87
Can patients have ACE is in pregnancy?
NO - teratogenic
88
Describe the WHO pain ladder
Step 1 Non-opioid analgesics
paracetamol
non-steroidal anti-inflammatory drugs (NSAIDs), including aspirin
Step 2 Mild opioid analgesics
codeine
dihydrocodeine
Step 3 Strong opioid analgesics
morphine
89
What laxative is recommended for opiate induced constipation?
Lactulose (osmotic laxative)
Docusate (stool softener)
Opiates inhibit gastric emptying and draw fluid in, leaving you with hard stools - therefore osmotics/stool softeners
90
Which 2 medications are usually prescribed weekly?
Bisphosphonates
| Methotrexate
91
Which 2 medications are usually taken at night?
Statins
| Amitriptylline
92
Which medication reduces hypoglycaemic awareness?
Beta blockers
This is because they reduce the beta affect of adrenaline so you dont get the typical adrenaline mediated symptoms eg. tremor, palpitations
93
Which ACE inhibitors are advised in pregnancy?
Labetolol or methyldopa
| ramipril is teratogenic in pregnancy
94
What must be communicated to patients started on tamoxifen?
Tamoxifen increases the risk of VTE
| It also increases the risk of endometrial cancer
95
When should gliclazide be taken?
In the morning with breakfast
96
Acute exacerbation of HF - what drug will quickly improve symptoms?
IV furosemide 40mg
97
What is the most immediate management in a patient with DKA?
IV fluid therapy
| after, give fixed rate insulin
98
Lamotrigine in pregnancy?
Slightly teratogenic but one of the safer antiepileptics - can be continued under specialist care but woman should take folic acid supplements
99
How often are blood tests required when starting methotrexate?
Weekly until therapy is stabilises
100
What parameters should be monitored with IV infusion of phenytoin?
ECG and blood pressure
101
What monitoring is involved when taking statins?
Measure LFTs taking statins then repeat within 3 months and at 12 months
102
What is the APTT ratio ?
It is the ratio of activated partial thromboplastin time to normal clotting time - it is the primary calculation used to monitor heparin therapy
103
How is STEMI managed?
1. ABC and 15L oxygen via non-rebreather mask
2. Aspirin 300mg oral
3. Morphine 5-10mg IV with metoclopramide 10mg IV
4. GTN spray/tablet
5. Thrombolysis or PCI
6. Beta blocker unless contraindicated (LVF/asthma)
7. Transfer to CCU
104
How is NSTEMI managed?
1. ABC and 15L oxygen via non-rebreather mask
2. Aspirin 300mg oral
3. Morphine 5-10mg IV with metoclopramide 10mg IV
4. GTN spray/tablet
5. Clopidogrel 100mg oral and LMWH
6. Beta blocker unless contraindicated
7. Transfer to CCU
105
How is acute LVF managed?
1. ABC and 15L oxygen via non-rebreather mask
2. Sit patient up
3. Morphine 5-10mg IV with metoclopramide 10mg IV
4. GTN spray/tablet
5. Furosemide 40-80mg IV
6. If inadequate response, isosorbide denigrate infusion with CPAP
7. Transfer CCU
```
LMNOP
Loop diuretics
Morphine
Nitrates
Oxygen
Position
```
106
How is anaphylaxis managed?
1. ABC and 15L oxygen via non-rebreather mask
2. Remove source of anaphylaxis
3. Adrenaline 500 micrograms 1:1000 IM
4. Chlorphenamine 10mg IV
5. Hydrocortisone 100mg IV
6. Asthma tx if wheezr
7. Amend drug chart allergies box
107
How is an acute asthma attack managed?
1. ABC
2. 100% oxygen via non-rebreather
3. Salbutamol 5mg NEB
4. Hydrocortisone 100mg IV (if severe) or prednisolone 40-50mg oral (if moderate)
5. Ipratropium 500 micrograms NEB
108
What drug can be added to the acute asthma attack algorithm if life-threatening?
Theophylline
109
How is a PE managed?
1. ABC
2. High flow oxygen
3. Morphine 5-10mg IV and metoclopramide 10mg IV
4. LMWH eg tinzaparin 175 units/kg SC daily
110
What can be given if a low BP in a PE?
IV gelofusine (colloid )- noradrenaline - thrombolysis
111
When should escalation from salbutamol be considered?
Nocturnal cough, tremor or use of salbutamol more than twice weekly
112
Which drugs have antimuscarinic side effects?
Anticholinergics
Atropine, cyclizine, amitriptyline
113
What is the management of mild to moderate AD?
Donepezil
114
What is the management of moderate to severe AD?
Memantine
115
What is the management of vascular dementia?
Target vascular risk factors - aspiring and ACEi/CCB
116
Why is domperidone safe for treating nausea in PD patients?
Despite it being a dopamine antagonist, it is not dangerous as it does not cross the BBB
117
How much potassium is usually given alongside saline/dextrose?
40mmol (max rate 10mmol/hr)
118
At what rate should maintenance fluids be given?
1L over 8-12 hours - about 125mil/hour
119
How do you prescribe blood products (not acutely haemorrhaging)?
1 Unit Red Blood Cells to be administered over 3 hours (1-3 hours is acceptable)
ALWAYS PRESCRIBE ONE UNIT AT A TIME
120
What should be prescribed for CAP?
Amoxicillin
Clarithromycin (penicillin allergic)
Doxycycline (COPD)
121
Which meds cause dyspepsia?
NSAIDs, steroids, aspirin
122
What is the most important initial action for a patient having a tonic-clonic seizure?
If less than 5 minutes - put in recovery position
| If over 5 minutes - Lorazepam 4mg IV
123
Codeine and driving?
Advise patients to take precautions if driving or operating heavy machinery
124
What are the sick day rules for Addisons patients?
Double usual steroid dose if unwell - if unable to take oral steroids should use rescue back of IM hydrocortisone instead and seek urgent medical advice
125
What is tornadoes de pointes and what causes it?
Polymorphic ventricular tachycardia, caused by long QT interval (usually from electrolyte disturbance)
126
How long does it often take for CRP to change over stating abx?
24 hours
127
What are the contraindications for NSAIDS?
```
No urine
Systolic dysfunction (HF)
Asthma
Indigestion
Dyscrasia (abnormal platelets)
```
128
What analgesia should be given for moderate pain?
Regular - paracetamol 1g 6 hourly
| PRN - paracetamol 30mg up to 6 hrly
129
What analgesia should be given for severe pain?
Regular - co-codamol 30/500 mg. 2 tablets 6 hourly
| PRN - morphine titrate up from 2.5mg to 10mg 6 hourly
130
Describe the pain ladder for neuropathic pain
```
Paracetamol
Gabapentin
Pregablin
Amitriptylline (used less due to antimuscarninc side effects)
Duloxetine
```
131
What medication class should not be prescribed with tramadol?
SSRIs - as risk of serotonin syndrome
132
Which drugs should be increased before surgery?
Corticosteroids
133
What do you do if a patient with renal impairment NEEDS CT with contrast?
Give a saline bolus to protect them
134
What is the drug treatment for neutropenic sepsis?
IV Tazocin
135
What should you monitor for therapeutic effect of diuretics?
Weight
136
T2DM, creatinine>150 - which drug to prescribe?
Gliclazide
137
How do you manage hypoglycaemia?
Conscious: Oral glucose 10-20g
Unconscious: IM glucagon
Severe/IV access: IV glucose 20%
138
What is the definition of a UC flare and how do you manage it?
Over 6 bowel movements and systemically unwell
Mild: oral prednisolone 30mg over 24 hours
Severe: IV hydrocortisone and fast fluids
139
Is warfarin safe in pregnancy?
Yes but not breastfeeding
140
Why should warfarin be given with LMWH at first?
In the first few days warfarin is pro coagulant
141
How long before surgery should the COCP be stopped?
4-6 weeks
142
What fluids are given for REPLACEMENT if HYPOVOLAEMIC?
0.9% saline, 500ml over 15 minutes
143
What fluids are given for REPLACEMENT if HYPOGLYCAEMIC?
5% glucose, 500ml over 15 minutes
144
What should you check before prescribing fluids?
- bladder not distended/palpable
- no raised JVP
- no peripheral oedema
145
How are electrolytes added to MAINTENANCE fluids?
1mmol/kg
146
What fluids are prescribed for MAINTENANCE?
1 salty 2 sweet
1L 0.9% NaCl + 20mmol K over 8 hours
1L 5% dextrose + 20mmol K over 8 hours
1L 5% dextrose + 20mmol K over 8 hours
147
What fluids are prescribed for RESUSCITATION?
500ml fluid bolus STAT <15min
250ml renal/cardiac failure/frail
REASSESS AND REPEAT UP TO 2000ml
148
Which laxatives are given in hepatic encephalopathy?
Lactulose
149
When should stimulant laxatives (eg. senna) not be prescribed?
Bowel obstruction
150
How is hyperkalemia treated?
- IV calcium gluconate 10ml 10%??? check
- 10 units actrapid
- 100ml of 20% IV dextrose
- Nebulised salbutamol
151
PALLIATIVE CARE: What do you give for secretions?
Hyoscine butylbromide 60mg/24h
152
PALLIATIVE CARE: What do you give for nausea?
Cyclizine 150mg/24h
153
PALLIATIVE CARE: What do you give for pain?
Morphine 10mg/24h if new
154
PALLIATIVE CARE: What do you give for agitation?
Midazolam 10-20mg/24h
155
What is the difference between spironolactone and furosemide in HF management?
Spironolactone improves PROGNOSIS
| Furosemide improves SYMPTOM
156
What is the 1st line management for AF going on for over 48 hours?
CCB (diltiazem, verapamil) or beta blockers
THINK VERA AND DILL, OLD LADIES
(If fast AF and beta blockers not allowed - use digoxin)
157
What is the 1st line management for AF going on for less than 48 hours?
```
Pharma cardioversion (amiodarone, flecanide) or DC cardioversion
THINK AMY AND FLEC, COOL YOUNG DRUMMERS
```
158
What investigation should be done before pharma cardioversion?
CXR - interstitial lung disease
159
When is cardioversion contraindicated?
Structural heart disease
160
What is the risk of cardioversion?
THROMBOEMBOLISM (this is why you only do it if less than 48 hours)
161
How is the therapeutic effect of ACEis monitored?
Exercise tolerance
162
Monitoring for vancomycin?
Renal function
163
Monitoring for lithium?
Weekly lithium levels til stable then every 3 months
| TFTs
164
Monitoring for statins?
ALT must be <105
| Stop if marked rise in CK
165
Monitoring for phenytoin?
Phenytoin levels
| If IV do ECG
166
Monitoring for ACE inhibitors?
Renal function 1-2 weeks after initiation
167
Monitoring for methotrexate?
LFT/renal 1-2 weeks at first then every 3 months
AVOID IN HEPATIC/RENAL DYSFUNCTION
168
Monitoring for olanzapine?
Fasting blood glucose
169
Monitoring for clozapine?
FBC weekly for 18 weeks
170
ECG monitoring for antipsychotics?
Only if existing cardiovascular disease - looking for long QT
171
Monitoring for amiodarone?
CXR
172
Monitoring for gentamicin?
Gentamicin levels
High trough - increase drug interval to clear drug
High peak - reduce dose
173
Monitoring for digoxin?
Measure creatinine
174
Monitoring for valproate?
ALT
175
Monitoring for carbimazole?
FBC - agranulocytosis
176
Monitoring for tacrolimus?
Trough level (this is an immunosuppressive drug given in organ transplant)
177
Monitoring for cyclosporin?
Renal function
178
In a bleed, if patient very hypotensive what do you give first?
FLUIDS stat then bloods
179
After 2/3 units of blood transfusion what do you give?
FFP - this is to prevent DIC
nb - normally dont give blood until Hb about 70
180
What drug is given in:
a) wernickes encephalopathy?
b) prevention of withdrawal?
c) prevention of relapse?
a) pabrinex (vitamin replacement)
b) chlordiazepoxide
c) acamprosate
181
What is 5mg prednisolone in hydrocortisone?
20mg
182
How should you manage a GI bleed?
1. ABC and oxygen
2. Insert 2 large bore cannula and catheter
3. Give crystalloid/colloid
4. Cross match 6 units of blood
5. Correct clotting abnormalities
6. Camera (endoscopy)
7. Stop culprit drugs (NSAIDS, aspirin, warfarin, heparin)
8. Call surgeons in severe
183
In a GI bleed when do you give a crystalloid and when a colloid?
Normal/high BP - crystalloid eg. saline
| Low BP - colloid eg. gelofusine
184
How should you manage bacterial meningitis?
1. ABC
2. High flow oxygen
3. IV fluids
4. IV dexamethasone (blunts immune response)
5. LP and maybe CT head
6. 2g cefotaxime IV (about 20 min after dexamethasone)
185
How should you manage a seizure?
1. ABC
2. Recovery position with oxygen
IF 5 MINS - STATUS EPILEPTICUS
3. 2-4mg lorazepam IV or 10mg buccal midazolam
4. Repeat lorazepam
5. Inform anaesthatist
6. Phenytoin infusion
7. Intubate then propofol
(check NICE guidelines!)
186
How should you manage an ischaemic stroke?
1. ABC
2. CT head
3. If aged >80yrs and onset <4.5hours ago consider thrombolysis
4. Aspirin 300mg oral
If haemorrhage stroke discuss with neurosurgery, do not give aspirin or thrombolysis
187
How do you diagnose hyperglycaemic hyper osmotic nonketotic (HONK) coma?
- Hyperglycaemia (BM >35mmol/L)
- Hyperosmotic (osmolality >340mmol/L)
- Non ketonic (no ketones present)
188
How do you diagnose DKA?
- Diabetic (BM often >11)
- Ketones (blood ketone >3)
- Bicarb <15 or pH <7.3
189
How do you manage DKA/HONK?
1. ABC
2. IV fluids (1L stat then 1L over 1 hour then 2 hours then 4 hours then 8 hours) - half this if HONK
3. Sliding scale insulin
4. Look for cause
5. Monitor BM, K and pH
190
How do you manage AKI?
1. ABC
2. Cannula/catheter with strict fluid monitoring
3. IV fluid: 500ml stat then 1L 4 hourly
4. Look for cause and complications (fluid overload, hyperkalemia, acidosis)
5. Monitor U&E and fluid balance
191
How do you manage acute poisoning?
1. ABC
2. Cannula/catheter with strict fluid monitoring
3. Supportive measures (IV fluids and analgesia if appropriate)
4. Correct electrolyte disturbance
5. Reduce absorption (eg gastric lavage, irrigation, charcoal)
6. Increase elimination (eg naloxone, NAC, flumanezil)
7. Psych management
192
What are the antidotes for:
a) opiate overdose?
b) paracetamol overdose?
c) benzo overdose?
a) naloxone - if low RR or low GCS
b) NAC - use treatment nomogram
c) flumazenil
193
Describe the NICE treatment of hypertension
Step 1 - ACE inhibitor/ARB or CCB (if aged >55 or black)
Step 2 - Add whichever one hadn't been used
Step 3 - Add thiazide-like diuretic (eg bendroflumethiazide)
Step 4 - Add further diuretic, alpha blocker or beta blocker
194
At which step of the hypertension treatment algorithm are you said to be treatment resistant?
Step 4
195
When do you treat HTN?
BP >150/95 or
| BP >135/85 + vascular disease/hypertensive organ damage
196
What BP do you aim for in patients with HTN?
135/85 (home reading)
| 145/95 if over 80yrs old
197
How is chronic heart failure managed?
1. ACEi + B-blocker
2. Increase doses if inadequate
3. Add ARB
4. Add hydralazine or isosorbide mononitrate (afro caribbean)
4. Add spironolactone (others)
198
What score is used to calculate risk of stroke in AF?
CHA2Ds2-VASc score
If 0 - consider aspirin 75mg daily
If 1 - use aspirin or warfarin (aim INR 2.5)
If 2 - use warfarin
199
How is stable angina managed?
ANTI-ANGINAL DRUG - beta blocker or CCB (try both separately before adding nitrate, isosorbide mononitrate or nicorandil)
SYMPTOM RELIEF - GTN
SECONDARY PREVENTION - aspirin, statin
200
How is asthma managed?
1. SABA
2. Add ICS
3. Add LABA, consider LTRA or theophylline
4. Increase ICS to 2000, add fourth drug (as above or beta agonist)
5. Add oral steroid
201
How is diabetes managed?
1. Metformin 500mg oral or Gliclazide 40m (if underweight or creatinine >150)
2. Increase drug dose to max tolerated
3. Add sulphonylurea if on metformin or glisten if on gliclazide
4. Add insulin
202
What is 1st line for PD?
Cobeneldopa or cocareldopa
| consider ropinirole or rasagiline if very mild
203
Which drug is 1st line for generalised tonic clonic seizures?
Sodium valproate
204
Which drug is 1st line for absence seizures?
Sodium valproate or ethosuximide
205
Which drug is 1st line for myoclonic seizures?
Sodium valproate
206
Which drug is 1st line for tonic seizures?
Sodium valproate
207
Which drug is 1st line for focal seizures?
Carbamazepine or lamotrigine
208
Which drug is 1st line for alzheimers?
Mild - AChE inhibitor eg. donepezil, rivastigmine, galantamine
Severe - NMDA antagonist eg. memantine
209
What drug is used in Crohns for:
a) flares?
b) inducing remission?
a) Prednisolone oral or hydrocortisone IV
| b) Azathioprine
210
What drug is used in RA for:
a) flares?
b) inducing remission?
a) methyprednisolone, ibuprofen
| b) methotrexate, DMARDs
211
In RA, when would you add TNFa inhibitors to management?
Failure to respond to 2 DMARDS
212
Which laxative is best for faecal impaction?
Docusate - stool softener (if in doubt prescribe this??)
213
After initiation of ace inhibitors, when should renal function and U&E be checked?
1-2 weeks after initiation
TELL PATIENT PRECAUTIONS MUST BE TAKEN IN PATIENTS WHO ARE UNWELL AS RISK OF AKI
214
What are the symptoms of an AKI?
```
Too little urine leaving the body.
Swelling in legs, ankles, and around the eyes.
Fatigue or tiredness.
Shortness of breath.
Confusion.
Nausea.
Seizures or coma in severe cases.
Chest pain or pressure.
```
215
When should patients on steroids be prescribed a bisphosphonate?
If they are expected to be taking steroids for over 3 months
216
What are the sick day rules for insulin?
Increase total daily insulin - this is because blood glucose increases when unwell
(nb - may need to decrease if patient not eating anything)
217
What information should be communicated to patients on bisphosphonatewd?
The tablet needs to be swallowed with a full glass of water and the patient should remain upright for 30 mins after
218
What parameter should be checked before starting patients on statins?
ALT/AST - if raised 3x normal then statins are contraindications
219
What is the normal reference range for lithium?
0.4-1
| toxicity usually seen above 1.5
220
For a multiple daily dose regimen, what should the peak serum concentration of gentamicin be when treating endocarditis?
3-5mg/L
221
For how many weeks does FBC need to be checked after starting a patient on clozapine?
18 weeks
222
What ADRs are associated with aspirin?
Haemorrhage, peptic ulcers, tinnitus
223
What ADRs are associated with digoxin?
Nausea, D&V, blurred vision, confusion, drowsiness, xanthopsia and halo vision
224
What ADRs are associated with amiodarone?
Pulmonary fibrosis, thyroid disease, skin greying, corneal deposits
225
What ADRs are associated with statins?
Myalgia, abdo pain, increased ALT/AST, rhabdomyolysis
226
Name some drugs with narrow therapeutic index
Digoxin, warfarin, phenytoin
227
Name some drugs that require careful titration of dose
Antihypertensives, antidiabetic drugs (as over treatment can lead to clinically significant consequences)
228
What is the potential effect of metformin and alcohol interacting?
Lactic acidosis
229
What is the potential interaction of alcohol and MAOIs?
Hypertensive crisis
230
What is the potential interaction of alcohol and barbs/benzos/opiates?
Sedation
231
Name 4 examples of NSAIDS
Ibuprofen
Naproxen
Diclofenac
HIGH DOSE aspirin (low dose is NOT an NSAID)
232
Why should NSAIDS and ACE inhibitors not be prescribed together?
ACE inhibitors relax vessels leaving the kidney
NSAIDS inhibit prostaglandins, which means that they constrict afferent renal vessels (vessels supplying the kidney).
BOTH OF THESE DRUGS REDUCE GFR AND REDUCE RENAL PERFUSION
233
What class of drug is amiloride?
Potassium-sparing diuretic
234
Why is lactic acidosis a risk with metformin?
1. Metformin inhibits hepatic gluconeogenesis
2. This process would usually mop up lactate
3. Without new sugar production, lactate can build up in the liver
235
Why is hypoglycaemia a risk with sulphonylureas eg. gliclazide?
1. Sulphonylureas modify calcium levels in beta cells
2. This calcium shift changes the cell membrane potential
3. This makes insulin granules bind more readily to the membrane and exocytose
4. As they act directly on insulin therefore there is a higher risk of hypo
236
Name 2 rapid-acting insulins
Insulin lispro - Humalog
| Insulin aspart - Novarapid
237
Name an intermediate-acting insulin
Isophane insulin - Humulin
238
Name 2 long-acting insulins
Insulin detemir - Levemir
| Insulin glargine - Lantus
239
Name 2 short-acting insulins
Actrapid
| Humulin S
240
What is the loading dose of aminophylline?
5mg/kg - remember this is often given as an infusion of 25mg/ml over 20 minutes???? check!
241
What is the difference between LMWH and unfractionated heparin?
Unfractionated - binds to antithrombin to stop clots growing, used in heart attacks and unstable angina, higher risk of heparin-induced thrombocytopenia, requires monitoring
LMWH - longer and more predictable, self-administered with no monitoring required, used in obstetrics eg. enoxaparin, dalteparin, tinzaparin
242
What is a suitable antibiotic choice for acne that has not responded to topical abx?
Tetracycline PO
243
TRUE OR FALSE - allopurinol can be continued in an AKI
FALSE - Allopurinol can accumulate in renal dysfunction and the BNF advises a max daily dose of 100 mg (or less if more severe renal injury) until renal function improves.
244
If eGFR is below 44, what antibiotic should be used in UTI?
Trimethoprim (avoid nitrofurantoin if possible!)
245
What antibiotic can cause cholestatic jaundice?
Co-amoxiclav - develops during or shortly after treatment
246
When increasing or decreasing levothyroxine, how big should the increments/decrements be?
25-50micrograms
247
Can you stop antiepileptics abruptly?
NO unless patient is toxic and in hospital environment where emergency seizure treatment may be instigated
248
Which anti epileptic causes SIADH?
Carbamazepine
249
Below which eGFR should metformin not be prescribed?
30
250
What is TENS?
Transcutaenous electrical nerve stimulation - this is a non-pharmacological treatment for pain
251
What is drip and suck?
The process of giving concomitant IV fluids to prevent dehydration whilst NBM, whilst using a nasogastric tube - often used in smalll bowel obstruction to relieve nausea
252
How much oxygen should be given to a C02 retainer ?
24% oxygen via a venturi mask
253
What parameter should be looked at for efficacy when reviewing a patient on antibiotics for pneumonia?
Respiratory rate - creps/consolidation take days/weeks to resolve
254
Which parameter should be monitored for resolution of DKA?
Serum ketones
255
TRUE OR FALSE - peak levels required in both gentamicin and vancomycin monitoring
FALSE - only gentamicin monitoring
256
What drug should be given in a milder allergic reaction?
Oral chlorphenamine
257
What are the 1st line drugs in palliative care?
Agitation: Midazolam
Secretions: Hyoscine butylbromide
Pain: Morphine (immediate + modified release)
Nausea: Cyclizine, metoclopramide
258
Which drugs increase the QT interval?
Cardiac drugs, macrolides, quinolones, antifungals, antipsychotics, antidepressants, domperidone, methadone
(NB - not all of each class, check in BNF)
259
Which drugs should you avoid prescribing with digoxin?
Anything that causes hypokalaemia (diuretics, lithium) as increased hisk of toxicity
260
What are the sick day rules for:
a) metformin
b) ACEis/NSAIDS
c) steroids
a) stop - risk of lactic acidosis
b) stop only if dehydration, vomiting etc
c) increase
261
Why should you not prescribe tramadol and codeine together?
Can cause confusion!
262
What analgesia do post op patients usuallyy get?
Regular codeine and post op morphine
263
What is the 1st line drug treatment for SVT?
Adenosine 6mg IV STAT (contraindicated in asthma, give verapamil)
NB - 1st line non drug treatment is the vasalva manoeuvre
264
Which drugs are contraindicated in heart failure?
Pioglitazone
Verapamil
NSAIDS (use with caution)
Class 1 antiarrhytmatics eg. flecanide
265
Why should anticoagulated patients not receive IM injections?
Risk of developing haematoma at injection site
266
What parameter should be measured to assess beneficial affect of UTI treatment?
Resolution of acute symptoms over 72 hours - catheter dipsticks are nearly always positive and dipstick urinalysis is unlikely to be helpful in judging whether infection has resoled
267
How should you manage a patient with myopathy and 5x normal CK, due to statin therapy?
1. Discontinue treatment
| 2. Restart at lower level if symptoms resolve and CK levels reduce to normal
268
What is the management for Wernickes encephalopathy?
Pabrinex
269
What is the management for alcohol withdrawal?
Chloridazepoxide
270
What is the management for alcohol addiction/to prevent relapse?
Acamprosate
271
What are the symptoms of anticholinergic excess?
MAD, RED, DRY, BLIND - from amitriptyline, paroxetine, antimuscarinics, antipsychotics
272
What are the symptoms of serotonin syndrome?
MAD, RED, WET, DILATED PUPILS - from SSRIs, SNRIs, TCAs, lithium , metoclopramide, opioids
273
Which antibiotic is first line in a patient with C diff colitis?
Metronidazole
274
What advice should be given to patients taking bisphosphonates?
- Tablets should be taken 30 min before breakfast weekly whilst sitting or standing, and swallowed with water
- Patients should see their dentist before treatment and have regular check ups throughout (risk of osteonecrosis of the jaw)
- Patients should stop treatment and seek medical attention if heartburn or dysphagia develops
275
What measure can reduce the risk of contrast-induced nephropathy?
IV 0.9% NaCl
276
What is a good opiate choice for patients with advanced cancer and comorbid CKD?
Fentanyl
| Morphine is really excreted therefore is not a great choice for someone with CKD
277
Which drugs should be used with caution in patients with IHD?
- NSAIDS
- Oestrogen containing meds (eg. COCP)
- Varenicline (used in smoking addiction)
278
What 2 drugs are first line for improving prognosis in chronic heart failure?
- ACE inhibitors
- Beta blockers
Start one drug at a time
