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PSA Flashcards

1
Q

Example of drug where trade name is acceptable?

A

tacrolimus- different preparations may lead to toxicity if used interchangeably

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2
Q

What enzyme system metabolizes majority of drugs in the liver?

A

Cytochrome P450 enzyme system in liver

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3
Q

What effect do enzyme inducers have on cytochrome P450 and consequently on drug effect?

A

Enzyme induces increase metabolism by P450 leading to reduced effect of drugs

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4
Q

What effect do enzyme inhibitors have?

A

Enzyme induces reduce metabolism by P450 leading to increased effect of drugs

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5
Q

PC BRAS mnemonic for enzyme inducers?

A

Phenytoin, carbamazepine, barbituates, rifampicin, alcohol (chronic excess), sulphonylureas

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6
Q

AODEVICES mnemonic for enzyme inhibitors?

A

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

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7
Q

I LACK OP mnemonic for drugs to stop pre-op?

A

Insulin, Lithium, Anti-coagulants/antiplatelets, COCP/HRT, K-sparing diuretics, Oral hypoglycaemics, Perndropil and other ACEi

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8
Q

Why should patients on long-term steroids have increased dose pre-op?

A

Long term steroids lead to adrenal atrophy- unable to mount adequate stress response leading to HYPOTENSION

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9
Q

Should beta blockers or CCBs be stopped pre-op?

A

No, may be detrimental

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10
Q

PReSCRIBER menominc for preventing pitfalls in prescribing?

A

Patient details, REaction, Sign front of chart, check for Contraindications, check Route for each drug, prescribe IV fluids if needed, prescribe Blood clot prophylaxis if needed, prescribe antiEmetic if needed, prescribe pain Relief if needed

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11
Q

How do you ensure patient details are correct?

A

Write 3 pieces of info (name, DOB, hospital number), or use addressograph sticker. If amending chart, make sure it is the write patients’

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12
Q

How to ensure you are aware of reactions?

A

Fill in allergy/reaction box on front of chart. If ammending- check box before prescribing

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13
Q

4 groups of drugs need to be aware of contraindications for?

A

drugs that increase bleeding, steroids, NSAIDs, antihypertensives

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14
Q

Drugs that increase bleeding include?

A

antiplatelets (e.g. aspirin), anticoagulant (e.g. warfarin, heparin)

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15
Q

What are drugs that increas bleeding contraindicated for?

A

pts who are bleeding, suspected of bleeding or at risk of bleeding (e.g. prolonged PT in liver disease)

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16
Q

STEROIDS mnemonic for steroid side-effects/contraindications?

A

Stomach ulcers, Thin skin, oEdema, Right and left heart failure, Osteoporosis, Infection incl. candida, Diabetes, Cushing’s Syndrome

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17
Q

NSAID mnemonic for contraindications of NSAIDs?

A

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

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18
Q

Which NSAID is not contraindicated for heart failure, renal failure or asthma?

A

aspirin

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19
Q

Side-effect of all antihypertensives?

A

hypotension incl. postural

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20
Q

Which antihypertensives can cause bradycardia?

A

beta blockers

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21
Q

Which antihypertensives can cause electrolyte disturbance?

A

ACEi, diuretics

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22
Q

Which antihypertensive class causes dry cough?

A

ACEi

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23
Q

Which antihypertensive class causes wheeze in asthmatic/worsening of acute HF?

A

beta blockers

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24
Q

Which antihypertensive class causes peripheral oedema and flushing?

A

CCBs

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25
Q

Which antihypertensive class can cause renal failure?

A

diuretics

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26
Q

Which specific type of diuretic can cause gout?

A

loop diuretics

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27
Q

Which specific type of diuretic can cause gynaecomastia?

A

K-sparing diuretics

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28
Q

If patient is vomiting, what route shoudl anti-emetics be given by?

A

not oral e.g. IV, SC, IM

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29
Q

If patient is vomiting should route of other oral drugs be changed?

A

no should continue as can be complicated to change everything

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30
Q

Should patients NBM still recieve oral medication?

A

yes including pre-op

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31
Q

Two situations in which fluid prescription is necessary?

A

REPLACEMENT (for dehydrated/acutely unwell patient), MAINTENANCE (patient who is NBM)

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32
Q

Which fluid is given as replacement normally?

A

saline 0.9%

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33
Q

If hypernatraemic/hypoglycaemic which fluid is used for replacement insead?

A

dextrose 5%

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34
Q

If pt has ascites what fluid is given instead?

A

human-albumin solution. Albumin maintains oncotic pressure- saline would worsen it

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35
Q

If shocked with systolic BP<90 which fluid is given?

A

gelofusine- a colloid with high osmotic content so stays intravascularly

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36
Q

If shocked from bleeding but no blood available which fluid given for replacement?

A

give blood transfusion but if no blood available give colloid first

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37
Q

What measures are useful for assessing how fast fluid needs to be replaced?

A

BP, HR, urine output

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38
Q

If tachycardic or hypotensive, what fluid needs to be given immediately?

A

500ml bolus (250ml if HF), then reassess pt esp. HR, BP and urine output to assess response and speed of next bag

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39
Q

If only oliguric how should fluid be given?

A

1L over 2-4h then reassess patient esp. HR, BP and urine output to assess response and speed of next bag

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40
Q

How much fluid loss would reduced urine output (oliguria<30mL/H, anuria) indicate?

A

500ml

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41
Q

How much fluid loss would reduced urine output and tachycardia indicate?

A

1L depletion

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42
Q

How much fluid loss would reduced UO, tachycardia and shock indicate?

A

2L depletion

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43
Q

As a general rule how much fluid do adults require per 24 hours for maintenance?

A

3L IV fluid

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44
Q

AS a general rule how much fluid do elderly require per 24 hours for maintenance?

A

2L IV fluid

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45
Q

What different fluids are used for maintenance to ensure adequate electrolytes?

A

1L 0.9% saline, 2L 5% dextrose

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46
Q

How much potassium do patients require per day?

A

40mmol per day e.g. 20mmol in two bags

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47
Q

What is the max rate of IV potassium delivery?

A

10mmol/hour

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48
Q

If giving 3L per day how fast do you give for maintenance?

A

8 hourly bags

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49
Q

If giving 2L per day how fast do you give for maintenance?

A

12 hourly bags

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50
Q

What should you monitor to check what to give patients for maintenance?

A

U&Es

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51
Q

How do you check the patient isn’t fluid overloaded?

A

JVP, peripheral/pulmonary oedema

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52
Q

Why do you need to check if patient’s bladder is palpable before prescribing fluids?

A

signifies urinary obstruction as cause of reduced urine output,

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53
Q

What sort of blood clot prophylaxis do most patients recieve in hospital?

A

compression stockings, LMWH (e.g. dalteparin)

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54
Q

Which patients should not be prescribed warfarin or heparin?

A

if patient is bleeding or at risk of bleeding- incl. recent ischaemic stroke

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55
Q

Which patients should not recieve compression stockings?

A

those with peripheral artery disease- can cause acute limb ischaemia

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56
Q

What antiemetics are usually given?

A

metoclopramide, cyclizine

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57
Q

Which patients should you avoid metoclopramide in?

A

a dopamine antagonist, avoid patients with Parkinson’s disease due to risk of exacerbation, young women due to risk of dyskinesia i.e. unwanted movements especially due to dystonia

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58
Q

How do thiazide diuretics cause hypokalaemia?

A

increase K excretion in kidneys

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59
Q

What kind drug is bendroflumethiazide?

A

thiazide diuretic

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60
Q

How can lisinopril affect potassium?

A

can cause hyperkalaemia

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61
Q

What class of drugs do metoclopramide and domperidone belong to?

A

dopamine antagonists

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62
Q

Why is domperidone safer than metoclopramide for Parkinsons

A

domperidone can’t cross the BBB

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63
Q

What class of drug is cyclizine?

A

anti-histamine antiemetic

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64
Q

How do ACEi lead to dry cough?

A

increased accumulation of bradyinin as less is degraded by ACE

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65
Q

How do ACEi lead to hyperkalaemia?

A

reduced aldosterone production->reduced K excretion in kidneys

66
Q

How does ibuprofen cause stomach problems?

A

inhibits prostaglandin synthesis needed for gastric mucosal protection from acid.

67
Q

How do oral steroids cause stomach problems?

A

inhibit gastric epithelial renewal thus predisposing to ulceration

68
Q

How does ibuprofen affect kidneys?

A

inhibits prostaglandin synthesis which reduces renal artery diameter (and blood flow), thereby reducing kidney perfusion and function.

69
Q

How does ramipril affect kidneys?

A

ACEi so reduces angiotensin II production necessary for glomerular filtration when renal blood flow is reduced

70
Q

Causes of microcytic anaemia?

A

IDA, thalassaemia, sideroblastic

71
Q

Causes of normocytic anaemia?

A

ACD, acute blood loss, haemolytic, renal failure

72
Q

Causes of macrocytic anaemia?

A

B12/folate deficiency, excess alcohol, liver disease, hypothyroidism, myeloproliferative/myelodysplastic/multiple myeloma

73
Q

Causes of high neutrophils?

A

BACTERIAL INFECTION, tissue damage (inflammation/infarct/malignancy), steroids

74
Q

Causes of low neutrophils?

A

VIRAL INFECTION, CLOZAPINE, CARBIMAZOLE, chemotherapy or radiotherapy

75
Q

Causes of high lymphocytes?

A

VIRAL INFECTION, lymphoma, CLL

76
Q

Causes of low platelets due to reduced production?

A

infection (usually viral), DRUGS (esp. penicillamine e.g. rheumatoid arthritis treatment), myelodysplasia/myeloma/myelofibrosis

77
Q

Causes of low platelets due to increased destruction?

A

HEPARIN, hypersplenism, DIC, ITP, HUS/TTP

78
Q

Reactive causes of high platelets?

A

bleeding, tissue damage, post-splenectomy

79
Q

Primary causes of high platelets?

A

myeloproliferative disorders

80
Q

Causes of hypovolaemic hyponatraemia?

A

fluid loss esp. DIARRHOEA/VOMITING, Addison’s, DIURETICS

81
Q

Causes of euvolaemic hyponatraemia?

A

SIADH, psychogenic polydipsia, hypothyroidism

82
Q

Causes of hypervolaemic hyponatraemia?

A

HEART FAILURE, RENAL FAILURE, liver failure (causing hypoalbuminaemia), nutritional failure (causing hypoalbuminaemia), thyroid failure (hypothyroidism can be euvolaemic too)

83
Q

Causes of hypernatraemia?

A

dehydration, drips (i.e. too much saline), drugs (e.g. effervescent tablet prep or IV prep with high Na content), diabetes insipidus

84
Q

DIRE mnemonic for hypokalaemia?

A

DRUGS (loop and thiazide diuretics), Inadequate intake or intestinal loss, Renal tubular acidosis, Endocrine (Cushing’s/Conn’s)

85
Q

DREAD mnemonic for hyperkalaemia?

A

DRUGS (K-sparing diuretics and ACEi), RENAL FAILURE, ENDOCRINE (Addison’s), ARTEFACT (very common due to clotted sample), DKA

86
Q

What does raised urea indicate other than renal failure?

A

upper GI bleed- protein like haem is broken down to urea by gastric acid

87
Q

How can you distinguish the above cause from renal failure?

A

If normal creatinine and raised urea ina patient who isn’t dehydrated, look at Hb-> if this has dropped then probably an upper GI bleed

88
Q

Cause of prerenal AKI?

A

dehydration (or if severe, shock) of any cause e.g. sepsis, blood loss, renal artery stenosis

89
Q

Cause of intrinsic AKI? mnemonic- INTRINSIC

A

Ischaemia (due to prerenal AKI causing acute tubular necrosis), Nephrotoxic Abx (esp. gentamicin, vancomycin and tetracyclines), Tablets (ACEi, NSAIDs), Radiological contrast, Injury (rhabdomyolysis), Negatively birefringent crystals (gout), Syndromes (glomerulonephritides), Inflammation (vasculitis), Cholesterol emboli

90
Q

Posterenal causes of AKI?

A

In lumen: stone or sloughed papilla. In wall: tumour (renal transitional cell), fibrosis. External pressure: BPH, prostate cancer, lymphadenopathy, aneurysm

91
Q

How can you distinguish prerenal AKI from Intrinsic/postrenal AKI?

A

Urea rise is much higher than creatinine rise in prerenal.

92
Q

LFT markers of hepatocyte injury/cholestasis?

A

bilirubin, ALT, AST, ALP

93
Q

LFT markers of synthetic function?

A

albumin, vit K dependent clotting factors (II, VII, IX and X) measured via PT/INR

94
Q

Prehepatic LFT derangement pattern? causes?

A

raised bilirubin. Caused by HAEMOLYSIS, also Gilbert’s and Crigler-Najjar syndromes

95
Q

Intrahepatic LFT derangement pattern? causes?

A

raised bilirubin and AST/ALT.. Fatty liver, HEPATITIS, CIRRHOSIS, MALIGNANCY, metabolic (Wilson’s haemochromatosis), Heart failure (causing hepatic congestion)

96
Q

Posthepatic LFT derangement pattern? causes?

A

Raised bilirubin and ALP. In lumne: gallstone, drugs causing cholestasis. In wall: tumour, PBC, PSC. Extrinsic pressure: pancreatic/gastric cancer, lymph node

97
Q

Drugs causing cholestasis?

A

flucloxacillin, coamoxiclav, nitrofuratoin, steroids and sulphonylureas

98
Q

What % width of the lungs should the heart be if cardiomegaly present on CXR?

A

more than 50%

99
Q

How does effusion appear on CXR?

A

white area solid and unilateral

100
Q

How does pneumonia appear on CXR?

A

unilateral and fluffy white

101
Q

How does oedema appean on CXR?

A

bilateral and fluff whiteness

102
Q

How does fibrosis appear on CXR?

A

bilateral and honeycomb white

103
Q

What direction does trachea move in collapse? pneumothorax?

A

towards collapse, away from pneumothorax

104
Q

What does widened mediastinum indicate? how do you differentiate?

A

right upper lobe collapse or aortic dissection. RUL collapse will have tracheal deviation

105
Q

What do lytic lesions in bones indicate?

A

metastasis

106
Q

What does not sharp costophrenic angles on CXR indicate?

A

pleural effusion

107
Q

What does air under the right hemidiaphragm indicate?

A

bowel perforation or recent surgery

108
Q

What does a triangle behing heart (sail sign) indicate?

A

left lower lobe collapse

109
Q

What would non-clear apices on CXR indicate?

A

TB or apical tumour

110
Q

ABCDE signs of pulmonary oedema?

A

Alveolar oedema (bat wings), Kerley B lines (interstitial oedema), Cardiomegaly, Diversion of blood to upper lobes, and pleural Effusinos

111
Q

How can one approximately calculate PaO2 from FiO2?

A

minus 10

112
Q

What is PaCO2 in Type 1 and Type 2 resp failures?

A

low or normal in Type 1, high in type 2

113
Q

Causes of Type 1 resp failure?

A

anything damaging heart or lungs causing SOB

114
Q

Causes of type 2 resp failure?

A

blue-bloaters subtype of COPD, less commonly neuromuscular failure or reactive chest wall abnormalities

115
Q

Cause of resp alkalosis?

A

rapid breathing, due to disease or anxiety

116
Q

Cause of resp acidosis?

A

type 2 resp failure

117
Q

Cause of metabolic alkalosis?

A

vomiting, diuretics, and Conn’s

118
Q

Causes of metabolic acidosis?

A

lactic acidosis, DKA, renal failurem ethanol/methanol/ethylene glycol intoxication.

119
Q

If sinus rhythm but PR interval is constant and over 1 large square what kind of HB?

A

1st degree

120
Q

IF PR interval is increasing then missing QRS what kind of HB?

A

second degree HB type 1

121
Q

If 2/3 P waves for every QRS what kind of heart block?

A

second degree HB type 2

122
Q

If no relation between P wave and QRS complex, what kind of HB?

A

third degree

123
Q

If QRS complex is more than 3 squares what does this suggest?

A

BBB

124
Q

What does an elevated ST segment indicate?

A

infarction or pericarditis

125
Q

What does a depressed ST segment indicate?

A

ischaemia, digoxin

126
Q

What do tented T waves signify?

A

hyperkalaemia

127
Q

Which leads is T wave inversion normal in?

A

aVR and I

128
Q

What does T wave inversion in other leads incidcate?

A

old infarction/LVH

129
Q

Common drugs requiring monitoring?

A

digoxin, theophylline, lithium, phenytoin, certain Abx (e.g. gentamicin, vancomycin)

130
Q

If inadequate response to the drug and low serum drug level…?

A

increase dose

131
Q

If adequate response to the drug and normal/low serum drug level?

A

no change required, if clinical response is adequate then aiming for therapeutic range is unnecessary

132
Q

If adequate response to the drug and normal/low serum drug level?

A

decrease dose - omit drug for a few days if appropriate

133
Q

What is zero order kinetics?

A

when rate of reaction/elimination is not proportional to concentration of drug e.g. phenytoin. Need to be especially care when increasing dose for drugs with this

134
Q

3 treatments for toxicity?

A

stop drug, supportive measures, give antidote

135
Q

Features of digoxin toxicity?

A

confusion, nausea, visual halos, arrhythmias

136
Q

Features of lithium toxicity (early)?

A

tremor

137
Q

Features of lithium toxicity (intermediate)?

A

tiredness

138
Q

Features of lithium toxicity (late)?

A

arrhythmias, seizures, coma, renal failure, and diabetes insipidus

139
Q

Features of phenytoin toxicity?

A

gum hypertrophy, ataxia, nystagmus, peripheral neuropathy, and teratogenicity

140
Q

Features of gentamicin/vancomycin toxicity?

A

otooxicity and nephrotoxicity

141
Q

Treatment of paracetamol overdose?

A

specfic management (NAC) and supportive management (IV fluids)

142
Q

Where is paracetamol metabolized, what antioxidant is this reliant on?

A

liver reliant on glutathione

143
Q

What toxic metabolite accumulates in paracetamol overdose causing liver damage?

A

NAPQI

144
Q

What class of drugs does bumetanide belong to?

A

loop diuretic

145
Q

Dose for oedema in young adults?

A

1mg in the moring then another dose 6-8hrs later if required

146
Q

Dose for oedema in elderly?

A

500mcg daily

147
Q

Dose for SEVERE oedema?

A

5mg daily

148
Q

Contraindications for bumetanide?

A

anuria, comatose/precomatose states associated with liver cirrhosis, renal failure, severe hyponatraemia/hypokalaemia

149
Q

What is lithium indicated for?

A

Mood stabilising drug for bipolar disorder, and refractory depression

150
Q

What may precipitate lithium toxicity?

A

dehydration, renal failure, drugs (diuretics, ACEi/ARB, NSAIDs, metranidazole)

151
Q

Features of lithium toxicity?

A

coarse tremor, hyperreflexia, acute confusion, seizure, coma, hypothyroidism

152
Q

Therapeutic range of lithium?

A

04-1.0 mmol/litre

153
Q

Drugs that may worsen epilepsy?

A

alcohol, cocaine, amphetamines, ciprofloxacin, levofloxacin, aminophylline, theophylline, bupropion, methylphenidate, mefenamic acid

154
Q

Drugs which decrease serum potassium?

A

thiazide diuretics, loop diuretics, acetazolamide

155
Q

Drugs which increase serum potassium?

A

ACEi, ARBs, spironolactone, K sparing diuretics, K supplements

156
Q

Adverse effects of carbimazole?

A

agranulocytosis, crosses the placenta but may be used in low doses during pregnancy

157
Q

Why do you avoid 5% glucose fluid in stroke patients?

A

Can cause cerebral oedema

158
Q

How much water, potassium/sodium/chloride, and glucose do people need a day?

A

water: 25-30 ml/kg/day. K/Na/Cl 1mmol/kg/day. glucose: 50-100 g/day

159
Q

When should Hartmann’s not be used?

A

if hyperkalaemic

160
Q

Starting dose of levothyroxine?

A

25mcg od

161
Q

Side effects of thyroxine therapy?

A

hyperthyyroidism, reduced bone mineral density, worsening of angina, AF

162
Q

Safe Abx in pregnancy?

A

penicillins, cephalosporins, trimethoprim

Finals Revision (9 decks)

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