PSA: Capsule Flashcards
1
Q
What are the proven benefits of HRT?
A
Control of menopausal sx & protection from osteoporosis
2
Q
What are the proven risks of HRT?
A
Inc incidence of endometrial ca, breast ca & VTE
3
Q
List CIs to HRT
A
Undx vaginal bleeding, severe liver disease, pregnancy, venous thrombosis pmhx, breast ca pmhx & incomplete tx of endometrial ca
4
Q
Which red flag sx require urgent cessation of the OCP?
A
Elevated BP, new onset headache/neuro sex, acute chest pain/SOB
5
Q
Which agents inc OCP metabolism?
A
Rifampicin, carbamazepine, phenytoin
Therefore inc risk of pregnancy
6
Q
Which agents do oestrogens antagonise?
A
Warfarin & steroids
7
Q
Which two routes can oxytocin be administered?
A
IV & IM
8
Q
The SEs of oxytocin
A
Uterine hyperstimulation & water intoxication and hyponatraemia as it has a similar structure to vasopressin
9
Q
Which drug can correct uterine hyperstimulation secondary to oxytocin?
A
Terbutaline
10
Q
MOA of mifepristone
A
Antiprogestogen & sensitises the myometrium to prostaglandin induced contractions
11
Q
MOA of misoprostol
A
Prostaglandin used in medical mx of miscarriage & after 48h from mifepristone in TOP
12
Q
What is the most common chronic condition in pregnancy?
A
Asthma, can be made worse by acid reflux, pts should use both reliever and preventer
13
Q
How is pulmonary function altered during N pregnancy?
A
A widened subcostal angle inc transverse diameter of the chest to oppose the effect of inc abdo volume & progesterone has a bronchodilator effect so forced spirometry generally remains unchanged
14
Q
Risks of asthma during pregnancy
A
PET, IUGR, PTB
Therefore continuous fetal monitoring is recommended
15
Q
Why are asthmatics at an inc risk of IUGR babies?
A
If uncontrolled the FEV1 is red
16
Q
When are antenatal steroids given?
A
A single course b/w 24 and 34 weeks of gestation who are at risk of preterm birth within 7 days to red morbidity and mortality of hyaline membrane disease
17
Q
What are the benefits of breastfeeding?
A
Transfer of IgA abs, red risk of infant D&V, if <6m LAM contraception
18
Q
Anti-HTN
A
Labetalol (asthma), nifedipine (rebound headaches), methyldopa (post natal depression), IV hydralazine
19
Q
Safest anti-epileptic to use in pregnancy
A
Lamotrigine
20
Q
How does acute dystonia usually px
A
Oculogyric crisis & torticollis
21
Q
How does tardive dyskinesia usually px
A
Orofacial dyskinesias such as lip smacking
22
Q
Tx for acute dystonia
A
Procyclidine
23
Q
Tx for tardive dyskinesia
A
Tetrabenazine
24
Q
How long do you need to wait for local prostate damage following catheterisation to pass before measuring the PSA?
A
2w
25
List two mood stabilising meds
Lithium & Sodium Valproate (only used in women of child-bearing age if on contraception)
26
Tx of paracetamol OD
N-acetylcysteine
27
Tx of opiate OD
Naloxone
28
Tx of benzo & zopiclone ODs
Flumazenil
29
Lithium toxicity >1.2, fatal >1.5, urgent tx >2.0
Early - N&V and tremor
Intermediate - tiredness
Late - irreversible nephrogenic DI, hypothyroidism, arrhythmias, seizures, delirium, coma, death
30
Meds a/w depression
Oral contraceptives, antihypertensives, statins, ranitidine & corticosteroids
Therefore important to ask about recent drug hx when diagnosing depression
31
How long is needed at an effective dose before deciding pt has failed to respond to antidepressant?
4w
32
After remission how long should antidepressants be continued for?
First ep 6m & second ep 2y
33
Duloxetine MOA
SNRI
34
Venlafaxine MOA
SNRI
35
Mirtazapine MOA
NaSSA
36
Reboxetine MOA
NARI
37
Uses of amitriptyline
Neuropathic pain e.g. herpetic neuralgia and phantom limb pain & migraine prophylaxis
38
Common SEs of amitriptyline
```
Dry mouth
Sedation
Blurred vision
Constipation
Postural hypotension
```
39
Rare SEs of amitriptyline
```
Urinary retention
Hyponatremia
Convulsions
Weight gain
Precipitation of glaucoma
Hepatic impairment
Cardiac dysrhythmias
```
40
CIs to prescribing amitriptyline
Known allergy, cardiac arrhythmias, complete heart block, immediately post MI, severe liver disease & acute porphyria
Think heart & liver
41
Which drug class should never be co-prescribed w TCAs?
MAOIs as the risk of serotonin syndrome is too high
42
What inc risk of ventricular arrhythmias w TCAs?
Beta-blockers & GA
43
Benzo withdrawal @ anytime up to 3w
Complaints: insomnia, anxiety, loss of appetite, wt loss, tremor, perspiration, tinnitus & perceptual disturbances
Physical signs: hyperthermia, HR >100bpm, RR >20bpm, variable BP, dilated pupils, palpitations, tremors, spasms, ataxia +/- dyskinesia & inc deep tendon reflexes
44
Normal therapeutic range for lithium
0.4-0.8mmol/L @12hrs post dose
45
Sodium valproate SEs
N&D&V, wt gain, hair loss w curly re-growth, tremor, ataxia
46
Sodium valproate OD
Hypotonia, hyporeflexia, met acidosis, impaired resp function, constricted pupils, CNS depression & coma
47
Outline the monitoring of lithium
If indicated ht, wt, FBC, ECG at initiation then once stable therapeutic levels every 3m & U&Es/TFTs every 6m
48
Carbamazepine SEs
Constipation & aplastic anaemia
49
Phenelzine MOA
Non-Selective Irreversible MAOI
50
Which foods can cause a hypertensive crisis w MAOIs?
Cheese & marmite
51
Sx of SSRI discontinuation syndrome following sudden cessation
Flu-like sx, dizziness, insomnia, N&V, sweating, agitation, electric shock sensations, tinnitus, headaches & irritability
52
SSRI SEs
N&V, diarrhoea, constipation, dyspepsia, hyponatraemia, insomnia & suicidal behaviour
53
Citalopram MOA
SSRI
54
Lofepramine MOA
Tricyclic Antidepressant
55
Trazadone MOA
Tricyclic Related Antidepressant
56
Moclobemide MOA
Selective Reversible MAOI
57
Outline a typical course of ECT
Twice a week for 3-6w
58
ECT SEs
Headache, memory problems, muscle aches
59
Meds that reduce renal excretion of lithium
ACEi, NSAIDS, diuretics particularly thiazides
60
What should be checked before starting atypical antipsychotic drugs?
Fasting blood glucose
61
Dose of sertraline
50mg OD then slowly inc up to 200mg OD
62
Sertraline MOA
SSRI
63
List three asthma tx that cause hypoK
Salbutamol, theophylline, prednisolone
64
Which electrolyte imbalance does SIADH cause?
HypoNa
65
Which asthma tx can potentially sig interact?
Salbutamol w theophylline, salbutamol w prednisolone, theophylline w prednisolone
66
List drugs where an inc dose of theophylline may be required
Carbamazepine, rifampicin, cigarettes
67
List drugs where an decr dose of theophylline may be required
Allopurinol, cimetidine, ciprofloxacin, erythromycin, propranolol, COCP
68
Ipratropium bromide SEs
Dry mouth, urinary retention, constipation, acute glaucoma
69
Salbutamol MOA
Selective short-acting beta-2 agonist
70
What can IV MgSO4 tx?
PET, acute severe asthma, severe diarrhoea w hypokalaemia & torsades de pointes ventricular tachycardia
71
Steroids + Cardiac Glycosides/Amphotericin
HypoK
72
Steroids + Phenytoin/Carbamazepine
Requires inc steroid dose
73
Which drugs do steroids antagonise?
ACEi, CCBs, nitrates, methyldopa
74
Asthma mod exacerbation BTS
PEF 50-75% best or predicted, inc sx, no features of severe asthma
75
Asthma severe exacerbation BTS
PEF 33-50% best or predicted, RR >25, HR >110, inability to complete sentences in one breath
76
Asthma life-threatening exacerbation BTS
PEF <33% best or predicted, SO2 <92% on air, paO2 <8kPa, silent chest, cyanosis, feeble respiratory effort, bradycardia, arrhythmia, hypotension, exhaustion, confusion, coma
77
Asthma near fatal BTS
Raised pCO2 >6.0kPa +/or requiring mechanical ventilation w raised inflation pressures
78
Tx of chronic asthma BTS
Step 1: inhaled SABA as required
Step 2: add ICS 200-800 micrograms per day
Step 3: add LABA, if no response stop and inc ICS dose, if benefit but not enough continue and inc ICS dose
Step 4: consider trial of other therapy - leukotrine receptor antagonists, theophylline, long-acting muscarinic receptor antagonists
Step 5: refer patient to specialist care - is always indicated if there has been a recent >/= severe exacerbation
79
Define sufficient control of asthma
Normal lung function (FEV1 +/or PEF >80% best or predicted) w minimal SEs and no daytime sx, night time awakening, rescue medication, exacerbations, daytime limitations inc exercise
80
What should you do before drug escalation in chronic asthma tx?
Check inhaler technique and concordance w tx regime
81
First line tx for allergic rhinitis
Daily oral antihistamines & nasal steroid spray
82
H1 and H2 Antags
H1 - second gen antihistamines
H2 - suppress gastric acid production
83
First and second gen antihistamines
First - chlorphenamine - 4-6h duration
Second - loratadine - 24h duration
84
First gen antihistamines MOA
Anti-muscarinic action
85
First gen antihistamines SEs
Blurred vision, dry mouth, constipation, urinary retention (particularly in elderly), sedation (can cross BBB)
86
List three ICS other than beclomethasone
Fluticasone, budesonide, mometasone
87
Advice for asthma control during pregnancy
Continue w current tx doses of SABA and ICS and emphasise importance of good control
88
How does theophylline toxicity manifest?
Serious arrhythmias & convulsions
89
What does tazocin contain?
Piperacillin and tazobactam
90
What does timentin contain?
Ticaricillin and clavulanic acid
91
What is aminophylline made up of?
Stable mixture of theophylline and ethylenediamine
92
When do you check serum theophylline levels?
18hrs after commencing tx w a target of 10-20mg/L
93
List some common drugs w narrow therapeutic indexes
Warfarin
Digoxin
Phenytoin
Theophylline
94
What do you monitor when giving IV aminophylline?
Oxygen sats (measure of therapeutic effect)
ECG (as it can precipitate cardiac arrhythmias)
95
Steroid in AECOPD
Prednisolone 30mg OD for 5d
96
Which infections does ciprofloxacin tx?
Salmonella, shigella, campylobacter
97
List indications for metronidazole tx
Anaerobic bacteria and giardia infections, part of H. pylori eradication therapy, rosacea, pseudomembranous colitis
98
When should quinolones be used w caution?
Children, pts over 60yo, in pregnancy, pts w epilepsy
99
What are quinolones a/w?
Tendon damage (esp in elderly, renal impairment, taking steroids) & aortic aneurysm/dissection
100
Loperamide CIs
High temp, bloody diarrhoea, abx associated colitis
101
What are the three main classes of parasites?
Protozoa, helminths, ectoparasites
102
Which class does ciprofloxicin belong to?
Quinolones
103
Which class does metronidazole belong to?
Nitroimidazoles
104
Which abx should you NOT drink alcohol whilst taking?
Metronidazole, tinidazole, sulfamethoxazole, trimethoprim
105
What happens if you drink alcohol whist taking metronidazole (or up to 3d after stopping)?
A disulfiram-like effect inc flushing, abdo pain and hypotension
106
Which conditions are grouped under dyspepsia?
Functional dyspepsia, drug-induced dyspepsia, PUD and GORD
107
What does a dx of functional dyspepsia require?
Sx w no abnormal structural/pathological findings
108
What sx would be alarming of underlying pathology?
Dysphagia, persistent vomiting, upper abdo mass, evidence of GI blood loss, unexplained wt loss
109
Which meds commonly cause upper GI sx?
Amlodipine, atorvastatin, oral corticosteroids
110
Tx of dyspepsia
Avoid drugs potentially causing sx, advise wt loss, avoidance of common precipitants and to raise head of the bed, antacid therapy as required, empirical PPI for 1m
If sx return after stopping PPI test for H. pylori, if pos tx, if neg offer low dose PPI and discuss using PPI on an as required basis
If there’s ever a concerning feature refer for 2w wait endoscopy
111
Antiemetics MOAs
Cyclizine - H1 antag first gen antihistamine
Prochlorperazine - DA antag in CTZ
Metoclopramide - DA2 antag in GI tract
Ondasetron - 5HT3 antag interacts w SSRIs and MAOIs
112
When is metoclopramide particularly useful?
N&V a/w gastroduodenal, hepatic and biliary disease
113
When must metoclopramide NOT be used?
Parkinsons pts & GI obstruction, perforation or haemorrhage as it inc gut motility
114
Metoclopramide SEs
Acute dystonic reactions esp in young women & QTc prolongation
115
Prochloperazine SEs
Tardive dyskinesia and akathisia
116
When is ondansetron particularly useful?
N&V post-op and that secondary to cytotoxic therapy
117
Ondansetron SEs
Constipation, headaches, flushing, bradycardia and chest pain
118
When is cyclizine particularly useful?
N&V as a result of underlying conditions
119
Tx of morning sickness
1. Cyclizine/Prochloperazine
| 2. Metoclopramide
120
When must cyclizine NOT be used?
HF pts
121
Def of constipation
The passage of hard stools less frequently than the patient’s own normal pattern
122
Laxative MOAs
OSMOTIC
Lactulose - semisynthetic disaccharide of fructose and galactose - gut bacteria break it down, it ferments to lactic and acetic acid, keeps fluid within bowel
Movicol - inert polymer of ethylene glycol - sequesters fluid within the bowel accelerating the transfer of gut contents
STIMULANT
Senna - anthracene derivatives - stimulates myenteric plexuses and thus peristalsis
Picolax - mg citrate w na picosulfate - powerful laxative but will not shift impacted stool
BULK-FORMING
Fybogel - ispaghula husk – inc faecal mass thereby stimulating peristalsis
POO-SOFTENER
Docusate - surface active compound - primarily a faecal softener but has a weak stimulant effect
123
Movicol SEs
Nausea, abdo distension, colicky pain
124
Lactulose SEs
Flatulence, cramps, diarrhoea and occasional electrolyte disturbances
125
When to use lactulose?
Anal fissures and hepatic encephalopathy
126
When would an enema or manual evacuation be appropriate?
Low faecal impaction
127
Laxative CIs
Bowel obstrc, known or suspected perforation, severe IBD +/- comps
128
Stimulant laxatives
Senna, sodium picosulfate, bisacodyl
129
Osmotic laxatives
Lactulose, movicol, miralax, milk of magnesia
130
Bulk forming laxatives
Fybogel and methylcellulose
131
Stool softener laxatives
Docusate na and arachis oil
132
Senna SEs
Cramping and colicky pain
133
Fybogel SEs
Flatulence and abdo distension
134
Pt w neuro problems, constipation, rectum full of hard stools
Combination of movicol and phosphate enemata, if unsuccessful manual evacuation, regular oral laxatives to prevent recurrence
135
Phosphate enema SE
Rectal irritation
136
Speed of onset for picolax, senna, fybogel
Picolax - 3h
Senna - 8-12h
Fybogel - days
137
Picolax SEs
N&V, abdo pain, distention, headaches, dizziness
138
What must pts on picolax be advised to do?
Drink plenty
139
When to use picolax?
Bowel prep prior to surgery
140
Lactulose CI
Bloating
141
Senna CIs
Cramps and colitis
142
Dose of loperamide
4mg followed by 2mg after each loose stool up to max of 16mg/24hrs
143
Two organisms that cause cellulitis
Group A Strept Pyogenes & Staph Aureus
144
Abx to tx cellulitis w dose
Benzylpenicillin 1.2g IV QDS or flucloxacillin 1g IV QDS
145
Which oral abx can you switch pts onto?
Phenoxymethylpenicllin or flucloxacillin
146
Which abx do you use if they’re penicillin allergic?
Erythromycin
147
When would you reduce penicillin doses?
Mod-severe renal impairment
148
When would you reduce clindamycin doses?
Any hepatic impairment
149
What is morphine metabolised to by the liver?
Inactive morphine 3 glucuronide and active morphine 6 glucuronide
Inactive 3 & active 6
150
What is a standard dose of morphine sulphate solution?
2.5-5mg four hrly as required
151
What affect does renal impairment have on opioids?
Inc and prolonged effect & inc cerebral sensitivity
152
What should you monitor in these pts?
RR & conscious level
153
List five drugs excreted by the kidneys that require dose reduction in renal impairment
Gliclazide, Gabapentin, Morphine, Digoxin, Gentamicin
154
What is the risk of gliclazide in pts w renal impairment?
Hypoglycaemia
155
Which drug can you switch morphine to if eGFR falls <30mls/min?
Oxycodone
156
What should you consider when the pt fails to respond to abx?
Wrong abx, wrong dx, not penetrating infected site, immunosuppressed, development of severe sepsis syndrome
157
List four causes of visible haematuria
UTI, stones, urothelial malignancy, IgA vasculitis
158
How would you remove large stones?
Percutaneous lithotripsy or surgically
159
What is the IgA disease rule of thirds?
1/3 asx just urine dip abnormalities
1/3 plus chronic kidney disease
1/3 progressive resulting in dialysis, transplantation, death
160
Tx of vasculitis
Watch and wait, immunosuppressive agents, ACEi to red proteinuria
161
Glucocorticoid SEs
Hyperglycaemia and diabetes, wasting and weakness, osteoporosis, fat redistribution, inc susceptibility to infection, peptic ulceration, cataracts, glaucoma, psychosis
162
Drugs that cause hyperK
ACEi & Spironolactone
163
Uses of spironolactone
Liver disease w ascites, hyperaldosteronism, severe HF
164
Which synthetic glucocorticoids have no salt retaining actions?
Betametasone and dexamethasone
165
Mineralocorticoid SEs
Fluid retention, hypokalaemia and hypertension
166
Adcal D3
Calcium 600mg + Cholecalciferol 10mcg
167
Calcichew D3
Calcium 500mg + Cholecalciferol 5mcg
168
List two egs of bisphosphonates
Alendronic Acid and Risedronate
169
What would you co-prescribe w long term steroid therapy esp in elderly?
Bisphosphonate, calcium carbonate, cholecalciferol
170
What should all pts on pong term steroid tx carry?
A steroid tx card
171
The three zones of the adrenal cortex
Zona glomerulosa - mineralocorticoids
Zona fasciculata - glucocorticoids
Zona reticularis - androgens
172
How should long term prednisolone dose be changed in pts who are acutely unwell?
x2
173
How do migraines typically px?
Unilateral, pulsating, mod to severe, building up in minutes to hours, a/w nausea and light sensitivity
174
If the headache is aggravated by physical activity which direction does this point
Migraines > Tension Type
175
How do tension type headaches typically px?
Bilateral, tightening, mild to mod, cranial tenderness, no nausea
176
What is a chronic headache?
>15 days/mnth for >3 mnths
177
Tension type tx
Acute - paracetamol or aspirin
Prophylaxis - amitriptyline
178
Migraine tx
Acute - ibuprofen, aspirin or triptan
Prophylaxis - propranolol
179
Headache red flags
New onset in pt over 50yo, thunderclap, wakes pt up, changes w posture, precipitated by physical exertion, abnormal neuro sx
PLUS promptly ix pts w signs of infection and history of HIV/cancer
180
What are bisphosphonates an analogue of?
Pyrophosphate
181
How do bisphosphonates work?
They are incorporated into the bony matrix, red bone resorption by promoting the apoptosis of osteoClasts, dec progression of bony mets
182
Routes of bisphosphonates
Oral + IV
183
Risks of bisphosphonates
Lifelong risk as long half life of untreatable and painful osteonecrosis
PLUS oesophagitis, peptic ulcers, fracture SEs
184
Uses of bisphosphonates
Osteoporosis, Pagets disease, bony mets, hyperCa of malignant disease
185
Sinister causes of a headache
VIVID
```
Vascular
Infection
Vision Threatening
Intracranial Pressure
Dissection
```
186
Systems affected in lidocaine OD
CNS & CVS
187
Sx of lidocaine OD
CNS - light headedness, perioral paraesthesia, dizziness, drowsiness, convulsions
CVS - myocardial depression, peripheral vasodilatation, hypotension, bradycardia
Plus central resp depression & allergic reactions (urticaria-anaphylaxis)
Does NOT affect gut motility
NB: draw back to ensure you’re not infecting into a vessel
188
Lidocaine MOA
Amide based LA, penetrates interior of axon, reversibly blocks Na channels, metabolised in liver & excreted in urine
189
What are the benefits of using using vasoconstrictors w LA?
Provide relatively bloodless field in which to work & prolongs the LA affect
190
List the nerve fibre order of sensitivity to lidocaine
Hint: based on fibre diameter
Pain, autonomic fibres, coarse touch, motor
Smaller C fibres - pain & temp
Larger A fibres - touch & power
191
What is paronychia?
Skin infection around the nail requiring LA ring block at the base of the finger before draining
192
Where must you NOT use LA w adrenaline?
Digits because of the risk of ischaemia
193
Why is toxicity more likely if lidocaine is infected into inflamed soft tissue?
Inc absorption
194
Which arrhythmia can IV lidocaine be used in tx?
Ventricular Tachycardia
195
Which heart conditions are contraindications to lidocaine tx?
SSS & AV block
196
Before injecting lidocaine
Brief hx for CIs, xray if possible radioopaque object still in wound, neurovascular exam of affected limb above and below level of injury
197
Name another LA that has a slower onset and longer duration than lidocaine
Bupivicaine
198
What method of pain relief should NOT be used in open wounds?
A cold spray
199
The onset and duration of lidocaine
Few mins & 1-2hrs
200
List ways to minimise the pain of LA infection
Allow LA to warm to room temp, infect slowly through small needle, use max dose, add adrenaline where possible to cause local vasoconstriction
201
How does rapid infection cause pain?
Inc hydrostatic pressure
