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PSA ALL Flashcards

1
Q

in an average healthy adult with no extra losses, what are the maintenance requirements for fluids

A

25-30ml/kg/day of water
1mmol/kg/day of sodium, chloride and potassium
50-100g/day of glucose to limit starvation ketosis

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2
Q

what is the normal amount of fluid loss per day

A

1ml/kg/hour

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3
Q

when you are replacing fluid, what uring output should you aim for

A

a minimum of 0.5ml/kg/hour

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4
Q

what is the quantity of fluid loss fro GI system

A

normally minor but can be considerable in D&V so quantify such losses

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5
Q

what is the normal quantity of insensible losses

A

500-800ml per day

but higher if pyrexic and sweating or if having open cavity surgery

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6
Q

sweating results in which electrolyte loss

A

sodium

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7
Q

diarrhoea and increased stoma output result in which electrolyte loss

A

sodium, potassium and bicarbonate

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8
Q

vomiting causes what type of electrolyte loss

A

sodium, potassium, chloride and hydrogen ions loss

thus leading to a hypochloraemic metabolic alkalosis (sometimes accompanied by a mild
hypokalaemia)

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9
Q

fill in this table with some signs of hypo and hypervolaemia

A
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10
Q

fill in this table with some signs of hypo and hypervolaemia

A
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11
Q

what four things should you consider when choosing a fluid and rate for fluid replacement

A

type of fluid loss
renal function
cardiac function
concomitant electrolyte abnormalities

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12
Q

how will IV NaCl 0.9% distribute itself once administered

A

isotonic with plasma and stays almost entirely in extracellular compartment
25% of the volume will go into the intravascular compartment
75% of the volume will go into the interstitial compartment

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13
Q

how much glucose is in 1000ml of glucose 5%

A

50 grams as it’s 50g/L of glucose

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14
Q

fill this in please

A
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15
Q

how does glucose 5% distribute over the various fluid compartments

A

distributes across all compartments according to their various contributions to total body water

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16
Q

name 5 colloids

A

blood
dextrans
gelatin (e.g. gelofusine)
human albumin solution
hydroxyethyl starch

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17
Q

what are the drawbacks of colloid

A

higher cost

small but well established risk of anaphylactoid reactions and anaphylaxis

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18
Q

what are the 5 Rs of prescribing fluids

A

Resuscitation
Routine Maintenance
Replacement
Redistribution
Reassessment

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19
Q

fluid resuscitation NICE recommendations

A
  • 500ml 0.9% NaCl over less than 15 minutes
  • monitor MAP, urine output etc to see if they are responsive
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20
Q

how do you calculate someone’s maintenance fluid and electrolyte requirements

A
  • 25-30ml/kg/day
  • 1mmol/kg/day of sodium, chloride and potassium each
  • and 50-100g glucose a day
  • special considerations in:
    • older adults
    • frail
    • renal failure
    • cardiac failure
    • malnourished at risk of refeeding
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21
Q

what are two complications of fluid overload?

A

dilutional hyponatraemia

and

pulmonary oedema

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22
Q

therapies for fluid overload

A
  • stop IV fluids
  • furosemide
    • causes diuresis and venodilation
  • sublingual nitrate
    • causes a reduction in preload - effect seen in 5 minutes
  • IV nitrate
    • provides an excellent and titratable pre and afterload reduction
      • must monitor BP as hypotension would mean you need to stop the infusion.
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23
Q

dose of IM adrenaline for anaphylaxis in adults over the age of 12

A

500 micrograms (which is 0.5mL of 1:1000 adrenaline)

can repeat after 5 minutes

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24
Q

dose of IM adrenaline for anaphylaxis for children aged 6-12

A

300 micrograms (which is 0.3mL of 1:1000)

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25
Q

dose of IM adrenaline for anaphylaxis in children aged younger than 6

A

150 micrograms (0.15mL of 1:1000)

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26
Q

factors that may contribute to non-adherance

A
  • social/economic factors
  • therapy related factors
  • condition related factors
  • patient related factors
  • health system factors
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27
Q

what is the definition of adherance

A

the extent to which a patient’s behaviour matches the agreed recommendations from the prescriber

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28
Q

how do you estimate a child’s weight

A
  • 0 to 12 months = (0.5 x age in months) + 4kg
  • 1 to 5 years = (2 x age in years) + 8kg
  • 6 to 12 years = (3 x age in years) + 7kg
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29
Q

how many milligrams (mg) in 1g

A

there are 1000 milligrams (mg) in 1g

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30
Q

how many micrograms in a milligram

A

there are 1000 micrograms in a milligram

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31
Q

how many nanograms are in a microgram

A

there are 1000 nanograms in a microgram

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32
Q

what does %w/w mean

A

percentage weight per weight

therefore hydrocortisone 0.5%w/w contains 0.5g hydrocortisone in 100g of the cream

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33
Q

what does %w/v mean?

A

weight per volume

in a sodium chloride 0.9% w/v solution contains 0.9g of sodium chloride in 100ml

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34
Q

what does %v/v

A

volumer per volume

in 1%v/v there is 1ml of actual drug in 100ml of the final product

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35
Q

what does 1:1000 mean

A

1:1000 means 1g in 1000mls

so 1:1000 adrenaline has 1mg per ml

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36
Q

gentamicin should be dosed according to a patient’s _____

A

ideal body weight

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37
Q

how do you calculate body surface area

A

BSA = weight(kg) X height (cm) / 3600

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38
Q

if converting oral morphine to fentanyl patch but their daily morphine is between the doses available of fentanyl patches what do you do

A

they need to be prescribed a fentanyl patch that is either slightly more or slightly less potent than their morphine dose

it is normal practice to use the lowest dose in the conversion range and then adjust according to response and tolerance

an immediate release preparation should be prescribed for breakthrough pain if required

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39
Q

how does the subcut dose compare to the oral dose of morphine

A

the subcutaneous dose of morphine is half the oral dose

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40
Q

where do you find the opiate conversion charts

A

medicines guidance > prescribing in palliative care

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41
Q

where do you find the steroid conversion charts

A

treatment summary > glucocorticoid therapy

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42
Q

where do you find the benzo conversion charts?

A

treatment summary > hypnotics and anxiolytics

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43
Q

what would an enzyme inducer/inhibitor do to INR in patient taking warfarin

A

inducer: INR drops
inhibitor: INR rises

inducers cause increased metabolism and elimination of warfarin and vice versa with inhibitors

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44
Q

mnemonic for remembering enzyme inducers

A
  • PC BRAS
    • Phenytoin
    • Carbamazepine
    • Barbituates
    • Rifampicin
    • Alcohol
    • Sulphonylureas
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45
Q

Enzyme inhibitors mnemonic

A
  • AODEVICES
    • Allopurinol
    • Omeprazole
    • Disulfiram
    • Erythromycin
    • Valproate
    • Isoniazid
    • Ciprofloxacin
    • Ethanol (acute intoxication)
    • Sulphonamides
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46
Q

patients who are on long term steroid therapy and surgery/sick day rules

A
  • commonly have adrenal atrophy so can’t mount an appropriate stress response to surgery
  • therefore BP may drop during surgery which is dangerous
  • so sick day rules are to double steroid dose when sick to meet increased steroid requirement
  • and in surgery they should be given IV steroid at induction
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47
Q

mnemonic for remembering which drugs should be stopped near surgery

A
  • I LACK OP
    • Insulin (they’ll be nbm so sliding scale started instead)
    • Lithium (day before)
    • Anticoagulants/antiplatelets
    • COCP (4 wks before surgery)
    • K-sparing diuretics (day of surgery)
    • Oral hypoglycaemics (they’ll be nbm so sliding scale started instead)
    • Perindopril and other ACE inhibitors
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48
Q

two antibiotics that contain penicillin

A

co-amoxiclav and tazocin

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49
Q

mnemonic for remembering the safety considerations of NSAIDs

A
  • NSAIDs
    • No urine (i.e. renal failure)
    • Systolic dysfunction (i.e. heart failure)
    • Asthma
    • Indigestion
    • Dyscrasia (clotting abnormality)

Aspirin is kind of exempt to the above since it is generally used at relatively low doses for the management of cardiovascular and cerebrovascular disease

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50
Q

mnemonic for remembering the side effects of steroids

A
  • STEROIDS
    • Stomach Ulcers
    • Thin skin
    • Edema
    • Right and left heart failure
    • Osteoporosis
    • Infections (candida)
    • Diabetes
    • cushing Syndrome
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51
Q

how to think about the side effects of anti-hypertensives

A
  • in three groups:
    • hypotension
      • including postural hypertension (earliest symptom)
      • can be caused by all antihypertensives
    • divide them into two mechanistic categories:
      • bradycardia
        • beta blockers and some CCBs
      • electrolyte disturbance
        • ACE inhibitors
        • diuretics
    • individual drug classes have specific side effects
      • ace inhibitors
        • dry cough
        • hyperkalaemia
      • B blockers
        • worsen acute heart failure (but help chronic)
        • cause wheeze in asthmatics
      • diuretics
        • can cause renal failure
        • thiazides can cause gout
        • potassium sparing diuretics can cause gynaecomastia
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52
Q

how to decide what fluid to give in fluid replacement

A
  • give all patients 0.9% saline unless:
    • they’re hypernatremic → 5% dextrose instead
    • they’re hypoglycaemic → 5% dextrose instead
    • they have ascites → human albumin solution instead
    • they’re shocked for bleeding → blood transfusion but crystalloid first if no blood available
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53
Q

as a general rule never prescribe more than ________ L of fluid for a sick patient

A

as a general rule never prescribe more than 2L of fluid for a sick patient

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54
Q

how to decide how much fluid and how quickly to give it in fluid replacement

A
  • if tachycardic OR hypotensive
    • give 500ml bolus immediately (<15mins)
    • unless Hx of heart failure then give 250ml
    • then reassess them
      • BP, urine output and HR
    • as general rule don’t prescribe more than 2L
  • if only oliguric (<30mL/hr)
    • then give 1L over 2-4hrs
    • then reassess them
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55
Q

IV potassium should not be given at a rate more than ____mmol/hr

A

IV potassium should not be given at a rate more than 10mmol/hr

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56
Q

three things to check when prescribing fluids in real life

A
  • patient’s U&Es to know what to give them
  • check they’re not fluid overloaded
    • raised JVP
    • peripheral/pulmonary oedema
  • ensure bladder isn’t palpable (obstruction)
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57
Q

as a general rule how much fluid do adults and the elderly need per 24 hours

A

adults require 3L/24 hrs

elderly require 2L/24hrs

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58
Q

quick and easy way to provide adequate electrolytes to an adult

A
  • “1 salty, 2 sweet”
    • generally require 3L per day
      • 1L 0.9% saline
      • 2L 5% dextrose
    • to add potassium (depending on U&Es)
      • pts need roughly 40mmol per day
      • so put 20mmol in two bags
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59
Q

which patients should not be prescribed compression stockings

A

those with peripheral arterial disease (absent foot pulses) as it may cause acute limb ischaemia

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60
Q

which patients to remember should not be on LMW heparin or other anticoagulants

A
  • patients who are bleeding or at risk of bleeding
    • this includes those who have had a recent ischaemic stroke within the last few months
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61
Q

who should not have metoclopramide

A
  • patients with parkinson’s disease
    • Metoclopramide is a dopamine antagonist so may exacerbate symptoms
  • young women due to the risk of dyskinesia
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62
Q

which antiemetics to use if patient is nauseated

A
  • regular antiemetics:
    • cyclizine
      • 50mg 8hrly IM/IV/orally
      • good first line
      • note causes fluid retention (don’t use in cardiac cases)
    • metoclopramide
      • 10mg 8hrly IM/IV if heart failure
      • metoclopramide first line in cardiac cases due to fluid retention that cyclizine causes
    • ondansetron
      • 4mg or 8mg 8hrly IV/oral
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63
Q

which antiemetics to use if the patient is not nauseated

A
  • as required medications
    • cyclizine
      • 50mg up to 8hrly IM/IV/orally
      • for most cases but cardiac ones due to fluid retention
    • metoclopramide
      • 10mg up to 8hrly IM/IV if heart failure
      • remember to avoid in parkinsons
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64
Q

what is the maximum dose of paracetamol in patients <50kg and what is it otherwise

A

in patients <50kg it is 500mg 6hrly

in other patients it is 4g in 24hrs

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65
Q

if someone has no pain what analgesia should you prescribe them

A
  • PRN:
    • paracetamol 1g up to 6hrly oral
    • ibuprofen 400mg up to 8hrly oral
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66
Q

if someone has moderate pain what analgesia should you prescribe them

A
  • regular:
    • paracetamol 1g 6hrly oral
  • PRN:
    • codeine 30mg up to 6hrly oral
    • ibuprofen 400mg up to 8hrly oral
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67
Q

if someone has severe pain what analgesia should you prescribe them

A
  • regular:
    • co-codamol 30/500, 2 tablets, 6hrly, oral
  • PRN:
    • morphine sulphate 10mg/5ml, 10mg up to 6hrly, oral
    • ibuprofen 400mg up to 8hrly oral
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68
Q

what is the first line treatment for neuropathic pain

A

amitriptyline 10mg oral nightly

or

pregabalin 75mg oral 12hrly

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69
Q

what analgesic for painful diabetic neuropathy

A

duloxetine 60mg oral daily

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70
Q

if you can’t use metoclopramide in parkinson’s what drug could you use instead

A

domperidone

metoclopramide and domperidone are both dopamine antagonists

domperidone doesn’t cross the BBB though

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71
Q

why do ACE inhibitors cause a cough

A

ACE breaks down bradykinin

bradykinin accumulation causes the cough

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72
Q

why do ACE inhibitors cause hyperkalaemia

A

they reduce aldosterone production and thus reduce potassium excretion in the kidneys

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73
Q

why does ibuprofen affect kidney function

A
  • inhibits prostaglandin synthesis
  • this reduces renal artery diameter
  • this leads to reduced kidney perfusion and function
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74
Q

why do ace inhibitors reduce kidney function

A

reduce angiotensin II activity necessary for preserving glomerular filtration when renal blood flow is reduced

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75
Q

what is the presentation of antimuscarinic toxicity (oxybutynin)

A

pupillary dilation with loss of accommodation

dry mouth

tachycardia (after a transient brady)

can cause confusion in the elderly

lower dose recommended in the elderky

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76
Q

why shouldn’t you take trimethoprim while on methotrexate

A

trimethoprim is a folate antagonist and so is methotrexate

it is a direct contraindication to patients taking methotrexate due to the risk of bone marrow toxicity

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77
Q

calcium channel blockers can cause which symptom which often gets treated with diuretics

A

they can cause peripheral oedema

this is often mistaken for heart failure

this is then mistakenly treated with a diuretic

both the diuretic and the calcium channel blocker can be discontinued

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78
Q

why should calcium channel blockers not be used with beta blockers

A

risk of bradycardia and hypotension

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79
Q

two common drugs that can precipitate bronchospasm in asthmatics

A
  • beta blockers (contraindicated in asthmatics)
  • NSAIDs (used in asthmatics if strictly necessary and with caution)
    • sort of ignore aspirin for this as it does it very rarely
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80
Q

the patient has asthma and is on ibuprofen but the question does not state that she has a wheeze - should you stop the NSAID?

A

the ibuprofen can be continued as it suggests that the asthma is not nsaid sensitive - proceed with caution.

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81
Q

causes of microcytic anaemia

A

iron deficiency anaemia

thalassaemia

sideroblastic anaemia

anaemia of chronic disease

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82
Q

causes of normocytic anaemia

A

anaemia of chronic disease

acute blood loss

haemolytic disease

chronic renal failure

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83
Q

causes of macrocytic anaemia

A

B12/folate deficiency

Excess alcohol

Liver disease

hypothyroidism

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84
Q

causes of hypernatraemia

A
  • causes all begin with D
    • dehydration
    • drips (i.e. too much IV saline)
    • drugs (e.g. tablets with too high sodium content)
    • diabetes insipidus
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85
Q

causes of high neutrophils

A

bacterial infection

tissue damage (inflammation/infarct/malignancy)

steroids

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86
Q

causes of low neutrophils

A

viral infection

chemotherapy or radiotherapy

clozapine

carbimazole

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87
Q

causes of high lymphocytes

A

viral infection

lymphoma

CLL

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88
Q

causes of low platelets

A
  • reduced production
    • viral infection
    • drugs
      • penicillamine for RA
    • myeloma
  • increased destruction
    • heparin
    • hypersplenism
    • disseminated intravascular coagulation
    • idiopathic thrombocytopenic purpura
    • thrombotic thrombocytopenic purpura
    • haemolytic uraemic syndrome
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89
Q

causes of high platelets

A
  • reactive
    • bleeding
    • tissue damage (infection/inflammation/malignancy)
    • postsplenectomy
  • primary
    • myeloproliferative disorders
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90
Q

causes of hyponatraemia

A
  • first you need to assess their fluid status
    • hypovolaemic
      • fluid loss (especially diarrhoea/vomiting)
      • addison’s disease
      • diuretics
    • euvolaemic
      • SIADH
      • psychogenic polydipsia
      • hypothyroidism
    • hypervolaemic
      • heart failure
      • renal failure
      • liver failure
      • nutritional failure causing hypoalbuminaemia
      • thyroid failure (hypothyroidism)
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91
Q

causes of SIADH

A
  • mnemonic SIADH
    • Small cell lung tumours
    • Infeciton
    • Abscess
    • Drugs (carbamazepine and antipsychotics)
    • Head injury
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92
Q

causes of hypokalaemia

A
  • mnemonic: dire
    • Drugs (loop diuretics and thiazide like diuretics)
    • Inadequate intake or intestinal loss (D&V)
    • Renal tubular acidosis
    • Endocrine (cushing’s and conn’s syndrome)
93
Q

causes of hyperkalaemia

A
  • mnemonic: dread
    • Drugs (ACE inhibitors and K-sparing diuretics)
    • Renal failure
    • Endocrine (addison’s)
    • Artefact (very common due to a clotted sample)
    • DKA
      • note that when insulin is given to treat DKA the K drops so it needs hourly monitoring +/- replacement
94
Q

what two things could a raised urea indicate

A
  • kidney injury
  • upper GI bleed

therefore if they have a raised urea with a normal creatinine (i.e. they don’t have pre-renal failure) then look at the Hb to make sure they haven’t had an upper GI bleed

95
Q

why might a raised urea indicate an upper GI bleed

A
  • if Hb broken down by gastric acid it will form urea
  • this urea will them be absorbed
  • the same thing will happen if you eat a big and bloody steak

for the same reason, a high protein diet can cause an elevated urea - it is product of amino acid breakdown

96
Q

what is classed as an elevated urea:creatinine ratio and what are the causes

A
  • Elevated ratio: >100:1
  • Causes:
    • Prerenal renal failure - hypovolaemia, sepsis, renal venoconstriction
    • Dehydration
    • Protein load - GI bleed (especially upper GI), high protein diet
    • Catabolic state - trauma, sepsis, starvation, corticosteroids
97
Q

what is classed as a reduced urea:creatinine ratio and what are the causes

A
  • Reduced ratio: <40:1
  • Causes:
    • Severe liver failure
    • Low protein intake - low protein diet, malnutrition, malabsorption, alcoholism
    • Muscle breakdown - body building, rhabdomyolysis
    • Pregnancy
98
Q

what biochemical disturbance will you see with a pre-renal AKI

A
  • increased urea:creatinine ratio
99
Q

what percentage of AKIs are pre-renal, intrinsic renal and post-renal

A
  • pre-renal: 70%
  • intrinsic renal: 10%
  • post-renal: 20%
100
Q

causes of pre-renal aki

A

dehydration

shock

blood loss

renal artery stenosis

101
Q

causes of intrinsic renal aki

A
  • mnemonic INTRINSIC
    • Ischaemia (due to pre-renal AKI causing necrosis)
    • Nephrotoxic antibiotics
    • Tablets (ACEI, NSAIDs
    • Radiological contrast
    • Injury (rhabdomyolysis)
    • Negatively birefringent crystals (gout)
    • Syndromes (glomerulonephritides)
    • Inflammation (vasculitis)
    • Cholesterol emboli
102
Q

common cause of AKI in RAS

A

renal artery stenosis and AKI is commonly caused by drugs such as ACEIs and NSAIDs

103
Q

name 3 nephrotoxic antibiotics

A

gentamicin

vancomicin

tetracyclines (e.g. those ending in cycline)

104
Q

causes of post-renal aki

A
  • obstruction
    • in lumen
      • stone
    • in wall
      • tumour
      • fibrosis
    • external pressure
      • BPH
      • pelvic mass
      • prostate cancer
105
Q

causes of a raised alk phos

A
  • mnemonic ALKPPHOS
    • Any fracture
    • Liver damage
    • Kancer
    • Paget’s disease of bone
    • Pregnancy
    • Hyperparathyroidism
    • Osteomalacia
    • Surgery
106
Q

what are the causes of pre-hepatic jaundice and what is the pattern of LFT derangement

A
  • causes
    • haemolysis
    • gilbert’s syndrome
    • crigler najjar syndrome
  • LFT derangement
    • increased bilirubin alone
107
Q

what are the causes of intra-hepatic jaundice and what is the pattern of LFT derangement

A
  • causes
    • fatty liver
    • hepatitis
    • cirrhosis
    • malignancy
    • metabolic
      • wilson’s
      • haemochromatosis
    • heart failure (causing hepatic congestion)
  • LFT derangement
    • raised bilirubin
    • raised AST and ALT
108
Q

causes of post-hepatic jaundice and what LFT derangement will you see

A
  • Causes
    • in lumen
      • stone
      • drugs that cause cholestasis such as:
        • flucloxacillin
        • co-amoxiclav
        • nitrofurantoin
        • steroids
        • sulphonylureas
    • in wall
      • tumour
      • PBC
      • PSC
    • extrinsic pressure
      • pancreatic or gastric cancer
109
Q

which drugs can cause cholestasis

A

flucloxacillin

co amoxiclav

nitrofurantoin

steroids

sulphonylureas

110
Q

what can cause hepatitis and cirrhosis

A
  • alcohol
  • viruses
    • hep a-e
    • cmv
    • ebv
  • drugs
    • paracetamol overdose
    • statins
    • rifampicin
  • autoimmune
    • PBC
    • PSC
    • autoimmune hepatitis
111
Q

when making or reviewing a prescription which things could be wrong with it

A
  • mnemonic: prescriber
    • PReSCRIBER
      • Patient details
      • Reaction
      • Sign the front of the chart
      • Contraindications
      • Route
      • IV fluids may be needed
      • Blood clot prophylaxis may be needed
      • antiEmetic if needed
      • pain Relief if needed
112
Q

how to check the quality of a film

A
  • PRIM
    • Projection
      • normally PA (PA if no label)
      • if AP heart will appear larger
    • Rotation
      • if distance between spinous process and clavicles is equal then no rotation
    • Inspiration
      • 7th anterior rib should intersect diaphragm
    • Markings
      • if red mark then radiographer has spotted an abnormality
113
Q

what size should the heart be on a CXR

A

it should be less than half the width of the lungs

114
Q

Why might a patient with a normal PaO2 on an ABG actually be hypoxic. How can you roughly calculate an appropriate PaO2 for a patient on oxygen?

A

if they are on oxygen then they may have a ‘normal’ PaO2 but you would expect them to have an even higher one. to work out whether they are hypoxic in an approximate way then you can do the following:

  • subtract 10 from the FiO2
  • if this number is lower than the PaO2 in kPa then the patient is not hypoxic

e.g. if a patient is on 60% oxygen with an PaO2 of 30kPa they are actually hypoxic because you would expect a PaO2 of 50kPa at least

115
Q

things that can cause type two respiratory failure

A
  • CO2 retaining COPD
  • neuromuscular failure
  • restrictive chest wall abnormalities
116
Q

causes of metabolic alkalosis

A

vomiting

diuretics

conn’s syndrome

117
Q

fill this in

A
118
Q

name 6 common drugs that require monitoring

A

digoxin

theophylline

lithium

phenytoin

gentamicin

vancomycin

119
Q

features of digoxin toxicity

A
  • confusion
  • nausea
  • visual halos
  • arrhythmias
120
Q

features of lithium toxicity

A
  • early:
    • tremor
  • intermediate:
    • tiredness
  • late:
    • seizures
    • arrhythmias
    • coma
    • renal failure
    • diabetes insipidus
121
Q

features of phenytoin toxicity

A

gum hypertrophy

ataxia

nystagmus

peripheral neuropathy

teratogenicity

122
Q

features of gentamicin toxicity

A

ototoxicity

nephrotoxicity

123
Q

features of vancomycin toxicity

A

ototoxicity

nephrotoxicity

124
Q

when is gentamicin levels checked

A

6-14 hours after the last gentamicin infusion was started

125
Q

which nomograms should you use for which dose of gent treatment

A
  • 7mg/kg dose: hartford nomogram
  • 5mg/kg dose: urban and craig monogram
126
Q

how should you act when checking gent levels

A
  • if point falls in q24hr area then continue at the same dosing interval
  • if point falls in the q36hr area then change to 36hr dosing
  • if the point falls in the q48hr area then change to 48hr dosing
  • if the point rests above the q48hr area then repeat the gentamicin level and only re-dose when the concentration is <1mg/L
127
Q

how to manage a patient who is over anticoagulated on warfarin depending on their INR and whether they are bleeding

A
128
Q

why do ace inhibitors cause renal failure

A
  • efferent vessels leaving the kidney rely on angiotensin II to constrict
  • this increases blood pressure in the kidney to a sufficient level for glomerulofiltration
  • therefore ACE inhibitors reduce pressure in the kidney and cause renal damage and renal failure

remember, the effect of this will be more in patients who have RAS or who are taking NSAIDs (except aspirin) which can constrict the renal artery

129
Q

when the INR is above the target range but below 6, how should you act

A

reduce dose of warfarin

130
Q

what is the most common regimen for neutropenic sepsis

A

combination of piperacillin, tazobactam and gentamicin

131
Q

common side effects of carbamazepine

A

neurological effects

GI upset

oedema

hyponatraemia due to an antidiuretic hormone like effect

132
Q

how does digoxin work

A

increases vagal tone

thereby reduces heart rate

also increases contractile force by acting directly on the myocytes

133
Q

when addisonian patients become sick what should they do

A

increase their intake of steroids to provide adequate cortisol for the stress response

134
Q

main thing in acute heart failure with pleural and peripheral oedema

A

furosemide is the mainstay of treatment of oedema in heart failure

in the acute setting it should be IV

135
Q

main thing in acute heart failure with pleural and peripheral oedema

A

furosemide is the mainstay of treatment of oedema in heart failure

in the acute setting it should be IV

136
Q

fill this in with the management steps

A
137
Q

draw out the treatment algorithm for adult tachycardia with pulse

A
138
Q

management of anaphylaxis

A
  • ABC and O2 (15L) by non-rebreather mask (unless COPD)
  • remove cause asap
  • give adrenaline 500 micrograms of 1:1000
  • if no response after 5 minutes
    • repeat dose of IM adrenaline
    • give fluid bolus
  • if persisting wheeze give asthma treatment
  • if no response despite two rounds of IM adrenaline it’s considered refractory anaphylaxis and early critical care support should be sought
  • after stabilisation consider cetirizine or chlorphenamine
139
Q

fill in this table with the different features of the different severities of asthma

A
140
Q

6 steps in the management of acute asthma

A
  1. ABC
  2. 100% oxygen by non-rebreather mask
  3. salbutamol NEB
  4. hydrocortisone IV (if severe/life threatening) and prednisolone oral (for all cases of acute asthma)
  5. ipratropium 500micrograms NEB
  6. aminophylline or magnesium sulphate in those with severe or if there has not been a good initial response to bronchodilator therapy (only under senior guidance)
141
Q

what is the treatment for pneumothorax

A
  • if secondary then they always need treatment
    • chest drain if >2cm or pt SOB or >50yo
    • otherwise aspirate
  • if tension pneumothorax
    • needle or cannula into 2nd intercostal space in the mid clavicular line on affected side
  • if primary
    • if >2cm on CXR or SOB then aspirate
      • if unsuccessful aspirate again
      • if still unsuccessful then chest drain
    • if <2cm and not SOB then discharge with outpatient follow up in 4 wks
142
Q

how to assess severity of pneumonia and how that affects treatment

A
  • CURB65
    • Confusion (AMT<8/10)
    • urea >7.5
    • Resp rate >30
    • Blood pressure systolic <90
    • Age >65

none or one of these things then they can be managed at home

two or more they need to be admitted

more than 3 and ITU admission should be considered

143
Q

CAP treatment

A

Low severity

Moderate severity

High severity

144
Q

what is the benzo antidote

A

flumazenil

145
Q

treatment for myoclonic seizures

A

valproate in men

levetiracetam in women

146
Q

treatment for tonic seizures

A

valproate for men

lamotrigine for women

147
Q

for focal seizures treat with

A

carbamazepine or lamotrigine

148
Q

for absence seizures treat with

A

ethosuximide or valproate

149
Q

what do you treat with for generalised tonic clonic seizures

A

valproate or lamotrigine

150
Q

what side effects does lamotrigine have

A

rash

rarely: stevens johnson syndrome

151
Q

what side effects does carbamazepine have

A

rash

dysarthria

ataxia

nystagmus

hyponatraemia

152
Q

what side effects does phenytoin have

A

ataxia

peripheral neuropathy

gum hyperplasia

hepatotoxicity

152
Q

what side effects does phenytoin have

A

ataxia

peripheral neuropathy

gum hyperplasia

hepatotoxicity

153
Q

what side effects does sodium valproate have

A

tremor

teratogenicity

weight gain

154
Q

what side effects does levetiracetam have

A

fatigue

mood disorders

agitation

155
Q

what is azathioprine used to treat and what is a special consideration in some people

A

crohns

10% of the population have low reserves of the enzyme that break it down so get abnormal accumulation when it is given in normal doses

this enzyme is called TPMT

check TPMT levels before starting treatment

if levels are deficient/absent then use methotrexate instead

if levels are low (but not deficient) then start azathioprine at a low dose

156
Q

never give a laxative if there is

A

evidence of obstruction

157
Q

in the acute setting furosemide should be given by which route?

A

IV not oral

158
Q

what are anti-muscarinic side effects

A
  • dry mouth with difficulty swallowing and thirst
  • dilation of the pupils with difficulty accommodating and sensitivity to light - i.e. blurred vision
  • increased intraocular pressure
  • hot and flushed skin
  • dry skin
  • bradycardia followed by tachycardia, palpitations and arrhythmias
  • difficulty with micturition - urinary retention
  • constipation
159
Q

carbimazole and carbemazepine both cause ____

A

neutropenia

160
Q

name two drugs that can precipitate parkinsonian symptoms even in patients that don’t have parkinson’s

A

metoclopramide and haloperidol

they do this because they’re dopamine antagonists

161
Q

IV or sublingual GTN

A

if patient’s pain doesn’t subside with sublingual GTN then you can try IV but IV is never used as first line

this is because sublingual normally works just as well, is cheaper and does not require the intensive monitoring that iV does

162
Q

considerations for contraception if patients are taking enzyme inducing drugs

A

parenteral administration is preferred

163
Q

ramapril and pregnancy

A

ACE inhibitors are teratogenic and if a patient is already taking ramipril they should be converted to labetalol

164
Q

which diabetes drug is associated with lactic acidosis

A

metformin

165
Q

what time of day should sulfonylureas be taken and why

A

in the morning because of their risk of hypos

if taken at night there’s increased risk of nocturnal hypos

166
Q

hallucination, increased temperature and agitation on citalopram

A

serotonin syndrome - life threatening complication of SSRIs and they should go to hospital immediately

167
Q

a 1% solution is equal to what

A

1g in 100ml

168
Q

what time of day should you give an ace inhibitor and why

A

at night since they can cause postural hypotension

169
Q

what time of day should you give an ace inhibitor and why

A

at night since they can cause postural hypotension

170
Q

insulin prescription in hyperkalaemia

A
  • 10 units of short acting insulin
    • (actrapid or novorapid)
  • in 100ml of 20% dextrose
  • over 30 minutes IV
171
Q

which antiepileptic drug has best safety profile in pregnancy

A

lamotrigine

172
Q

which antiepileptic should you not give in hyponatraemia

A

carbemazepine because it can cause an SIADH and may drop the sodium further

173
Q

which diabetes drug for if they’re overweight or underweight

A

normal or underweight → sulphonylureas

if overweight → metformin

174
Q

do not use metformin in patients with a creatinine above what

A

150mmol/L

175
Q

what are the two classic side effects of vancomycin and gentomicin

A

nephrotoxicity and ototoxicity

176
Q

what blood tests should you do before starting a statin

A
  • full lipid profile
  • liver enzymes
    • if more than 3 times normal then exclude from statin therapy
    • repeat at 3 and 12 months of treatment
  • creatinine kinase if thought to be at high risk of
    • FH of muscular disorders
    • personal history of muscular toxicity
    • high alcohol intake
    • renal impairment
    • hypothyroidism
    • elderly
177
Q

when is the recommended sampling time for lithium

A

12 hours after the last dose

178
Q

toxic effects are likely to manifest with lithium at what level

A

above 1.4mmol/L

179
Q

what are the classic side effects of ace inhibitors

A

hypotension

electrolyte abnormalities (hyperkalaemia and hyponatraemia)

AKI

dry cough

180
Q

side effects of B blockers

A

hypotension

bradycardia

wheeze in asthmatics

worsens acute heart failure (but helps chronic)

181
Q

what are the classic side effects of calcium channel blockers

A

hypotension

bradycardia

peripheral oedema

flushing

182
Q

what are the classic side effects of heparin

A

haemorrhage (especially if renal failure or <50kg)

heparin induced thrombocytopenia

183
Q

what are the classic side effects of warfarin

A

haemorrhage

note that it also has a pro-thrombotic effect in the few days that it takes to start working that’s why it needs to be bridged with heparin until INR exceeds 2

184
Q

side effects of digoxin

A

nausea

vomiting

diarrhoea

blurred vision

confusion

drowsiness

affected by potassium

185
Q

how does potassium affect digoxin

A

digoxin acts on the Na/K ATPase in the myocyte wall to slow heart rate

therefore changes in serum K levels change the effect of digoxin

low potassium increases digoxin effect

high potassium limits digoxin effect

186
Q

side effects of amiodarone

A
  • interstitial lung disease (pulmonary fibrosis)
  • thyroid disease (both hypo and hyper)
    • it’s structurally related to iodine hence amIODarone
  • skin greying
  • corneal deposits
187
Q

haloperidol side effects

A

dyskinesias

drowsiness

188
Q

clozapine side effects

A

agranulocytosis

189
Q

NSAID side effects

A
  • NSAID
    • no urine (renal failure)
    • systolic dysfunction
    • asthma
    • indigestion
    • dyscrasia
190
Q

rate statins in order or their risk of myalgias

A

simvastatin > atorvastatin > pravastatin > fluvastatin

191
Q

what are the classic side effects of statins

A

myalgia

abdo pain

increased AST/ALT (can be mild)

rhabdomyolysis

192
Q

management of statin induced myalgia

A
  • exclude rhabdo with CK level and urine dip
  • otherwise if symptoms are unacceptable or CK very high (>2000)
    • ensure needs statin
    • reduce dose
    • change to different statin with lower risk of myalgia
193
Q

if low gcs and diabetic what drug side effect should you think of

A

lactic acidosis from metformin

194
Q

name some enzyme inhibitors

A
  • AODEVICES
    • Allopurinol
    • Omeprazole
    • Disulfiram
    • Erythromycin
    • Valproate
    • Isoniazid
    • Ciprofloxacin
    • Ethanol (acute intoxication)
    • Sulphonamides
  • also
    • grapefruit juice
    • ketoconazole
195
Q

name some enzyme inducers

A
  • PC BRAS
    • Phenytoin
    • Carbamazepine
    • Barbiturates
    • Rifampicin
    • Alcohol (chronic)
    • Sulphonylureas
196
Q

which antibiotic must not be given to people taking methotrexate and why

A

trimethoprim

both are folate antagonists

taken together they can lead to bone marrow suppression, pancytopenia and neutropenic sepsis

197
Q

why does metformin cause lactic acidosis

A

because it acts on the liver to stop gluconeogenesis in order to control hyerglycaemia

lactate is usually taken up in gluconeogenesis and therefore lactate can build up in patients taking metformin

therefore metformin can cause a lactic acidosis

198
Q

why do sulphonylureas cause hypoglycaemia

give some examples of sulphonylureas

A

they act on the pancreas to increase release of insulin

therefore they increase insulin levels and can cause hypoglycaemia

e.g. gliclazide, glipizide, tolbutamide

199
Q

all heparins can contribute to what electrolyte abnormality

A

hyperkalaemia due to the inhibition of aldosterone synthesis

200
Q

are antiplatelet treatments usually stopped before surgery?

A

yes they are usually stopped one week before surgery

201
Q

SSRIs can cause which electrolyte imbalance and why

A

hyponatraemia due to inappropriate ADH secretion

202
Q

what should you do about INR on the day before surgery

A

if more than 1.5 on the day before surgery then give phytomenadione (vitamin K) 1-5mg PO using the IV preparation

203
Q

when is the POP effective after an enzyme inducer

A

progesterone only preparations have their efficacy reduced by enzyme inducing drugs such as topiramate or erythromycin

therefore an alternative method of contraception should be used during treatment and for 4 weeks afterwards

204
Q

what blood change is expected after starting an ace inhibitor

A

a small rise in creatinine <20% is expected after starting an ace inhibitor and does not require investigation or a change in prescription

just repeat U&Es in a week

205
Q

three drugs that can reduce lithium excretion

A
  • ACE inhibitors
  • diuretics
    • particularly thiazides
    • if a diuretic must be used then loop diuretics are safest
  • NSAIDs
206
Q

why should candesartan be suspended in AKI

A

because, in a similar way to how ACE inhibitors are nephrotoxic, ARBs are nephrotoxic

207
Q

can you use trimethoprim in folate deficiency

A

yes for a short course and with caution

208
Q

why must you not stop steroids suddenly

A

because if on long term systemic steroid therapy they may have developed adrenal insufficiency

209
Q

should men use contraception while taking methotrexate?

A

yes and for 6 months afterwards

210
Q

which electrolyte is most likely to be artefactally abnormal

A

K+

211
Q

if there’s severe hyperkalaemia but none of the DREAD features (apart from artefact) are present then what should you do

A

give calcium gluconate AND recheck the biochemistry

212
Q

Metformin in renal impairment

A
  • contraindicated if eGFR <30
    • give short acting sulphonylyurea such as gliclazide instead
  • caution if eGFR <45
213
Q

angio-oedema related to the build up of bradykinin can occur months after initiation of treatment with which class of drugs:

A

ACE INHIBITORS

214
Q

Why must statins not be used in liver disease

A

the liver disease could affect its metabolism

215
Q

what time of day are statins taken

A

at night since that’s when most cholesterol metabolism takes place

215
Q

what time of day are statins taken

A

at night since that’s when most cholesterol metabolism takes place

216
Q

name a dietary restriction with statins

A

grapefruit - it’s an enzyme inhibitor and therefore increases statin toxicity

217
Q

what should you do with your statin dose if you need to take an enzyme inhibitor such as clarithromycin

A

stop the statin because enzyme inhibitors increase toxicity and side effects of statins

218
Q

methotrexate monitoring

A
  • blood tests every 1-2 weeks until stabilised
  • then every 2-3 months
  • to monitor:
    • FBC
    • LFT
    • U&E

be advised to report symptoms of infection particularly sore throat

219
Q

during an episode of sickness what should happen to steroid dose

A

it should be doubled (sick day rules)

220
Q

if someone can’t take their oral pred due to being too nauseous what should you do?

A
  • they still need steroid therapy since they may have adrenal insufficiency
  • us the glucocorticoid therapy section to convert it to IM hydrocortisone
221
Q

a 1% solution contains how many grams in 100ml

A

1G IN 100ML IS A 1% SOLUTION

222
Q

how to choose between tramadol and codeine

A
  • based on side effects
  • both have typical opioid side effects
  • tramadol more likely to cause agitation/hallucinations particularly in the elderly
  • cocodamol more likely to cause constipation
    • so if they have diarrhoea then this is a good shout
223
Q

what time of day should laxatives be taken

A

night

224
Q

what laxative is stool is soft

A

not osmotics - try a stimulant such as senna or bisocodyl

225
Q

how long can consolidation take to clear on a chest x ray

A

6 weeks

226
Q

when should tacrolimus levels be measured

A

at their trough so just before the morning dose

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