PSA: Intro Week Flashcards
1
Q
What are the eight sections of the PSA?
A
1 - Prescribing 2 - Prescription Review 3 - Planning Mx 4 - Providing Info 5 - Calc Skills 6 - ADRs 7 - Drug Monitoring 8 - Data Interpretation Totals 200 marks in 2hrs
2
Q
How are the marks distributed over the exam?
A
8x Prescribing - 10 Marks (80) 8x Prescription Review - 4 Marks (32) 8x Planning Mx - 2 Marks (16) 6x Providing Info - 2 Marks (12) 8x Calc Skills - 2 Marks (16) 8x ADRs - 2 Marks (16) 8x Drug Monitoring - 2 Marks (16) 6x Data Interpretation - 2 Marks (12)
3
Q
What does PReSCRIBER stand for?
A
Pt details Reactions Sign CIs Route IV fluids necessary? Blood clotting prophylaxis necessary? Antiemetics necessary? Pain relief necessary?
4
Q
List the P450 inhibitors
A
SICK FFAAACES Dot COM Group Sodium Valproate Isoniazid Cimetidine Ketoconazole Fluconazole Fluoxetine Alcohol (Acute) Allopurinol Amiodarone Chloramphenicol Erythromycin Sulphonamides Disulfiram Ciprofloxacin Omeprazole Metronidazole Grapefruit
5
Q
P450 inhibitors w warfarin
A
Both inc INR so may need to reduce warfarin dose
6
Q
List the P450 inducers
A
PCC SSBAR Phenytoin Carbamazepine Cigarettes St Johns Wort Sulphonylureas Barbiturates Alcohol (Chronic) Rifampicin
7
Q
P450 inducers w COCP
A
Red effectiveness so ideally swap contraception for 4w but failing this: inc oestrogen to 50mcg, red/no pill free wk, advise adding barrier methods
8
Q
Which contraceptives are unaffected by EIDs?
A
Depo, mirena, copper iud
9
Q
Which method of contraception is a/w wt gain?
A
Depo PLUS irr bleeding, inc risk of osteoporosis, resumption of fertility delay up to 1yr
10
Q
Maintenance fluids in adults who are NBM every 24h
A
Provided N biochem: 1L 0.9% saline 2L 5% dextrose 40-60mmol KCl
11
Q
Drugs to stop before surgery
A
I LACK OP Insulin Lithium Anticoags/Antipl COCP/HRT K Sparing Diuretics Oral Hypoglycaemics Perindopril/ACEi
12
Q
When do you stop COCP/HRT before surgery?
A
4w
13
Q
When do you stop aspirin before surgery?
A
1w
14
Q
When do you stop warfarin before surgery?
A
5d Then start LMWH for a few days but withold the night before surgery and only restart both when surgeons are happy
15
Q
What do you do if INR >1.5 on the day before surgery?
A
Give 1-5mg vitamin K PO
16
Q
When do you stop lithium before surgery?
A
The day before
17
Q
When do you stop K sparing diuretics and Perindopril/ACEi before surgery?
A
On the day
18
Q
Which drug do you inc for surgery?
A
Steroids
19
Q
Aspirin SEs (3)
A
Haemorrhage, peptic ulcers, tinnitus
20
Q
List the CIs to drugs that inc bleeding (4)
A
Active bleeding, prolonged PT, heparin CI in acute stroke because risk of haemorrhagic transformation, warfarin CI w P450 inhibitors
21
Q
Blood clot prophylaxis
A
LMWH + TED stockings
22
Q
Name two different LMWHs w their prophylactic and tx doses
A
Tinzaparin - 4500U for proph and 175U/kg for tx Enoxaparin - 40mg for proph and 1.5mg/kg for tx
23
Q
How many units is 40mg enoxaparin?
A
4000U
24
Q
Alternative to LMWH in pts w VTE and needle phobia including dose
A
Apixaban 10mg BD for 7d
25
The CI to TED stockings
Peripheral arterial disease due to the risk of ALI
26
Anti-HTN SE
Postural hypotension therefore tend to take in the evening/night
27
What does midodrine tx? (2)
Dysautonomia and orthostatic hypotension
28
Which drugs inc risk of renal damage? (2)
ACEi and NSAIDs except aspirin
29
Why does red angiotensin-II lead to acute RF?
No efferent arteriole constriction when GFR reduces
30
Starting dose of ACEi in Hf pts
Ramipril 1.25mg OD Lisinopril/Enalapril 2.5mg OD
31
ACEi SEs (4)
Dry cough (inc bradykinin), acute RF (red Ang-II), hyperK (red aldosterone) and angioedema if AfroCaribbean pts
32
Beta-blocker SEs (3)
Bradycardia, wheeze, worsens acute HF
33
Drugs to avoid in pts w peripheral vascular disease (2)
ACEi and beta blockers
34
Dose of amlodipine used for HTN
5-10mg OD
35
Dose of verapamil used for rate control in AF
40mg 8hrly
36
Which factor X inhibitor can be used in AF?
Rivaroxaban 20mg OD w food
37
CCB SEs (3)
Bradycardia, peripheral oedema, flushing Plus verapamil causes constipation
38
Drugs causing ankle oedema (2)
CCBs and Naproxen
39
Digoxin SEs (6)
N+V, diarrhoea, blurred vision, confusion, drowsiness, xanthopsia
40
Diuretic SE
Hypoperfusion leads to RF
41
Frusemide SE
Gout
42
Spironolactone SE
Gynaecomastia
43
Which anti-HTNs cause hypoK? (2)
Loop diuretics and thiazides
44
What should be checked and corrected before starting amiodarone?
Serum potassium as it can cause hypoK
45
Antiemetics MOA
Antagonists to: H1 - Cyclizine DA - Phenothiazines DA2 - Metoclopramide & Domperidone 5HT3 - Ondansetron
46
Dose of cyclizine
PO/IV/IM 50mg 8hrly
47
When should you avoid using cyclizine?
Heart failure pts
48
Dose of metoclopramide
PO/IV/IM 10mg 8hrly
49
When should you avoid using metoclopramide?
Parkinsons pts & GI onstr/perf/haem NB: domperidone is safe in parkinsons because it doesn’t cross the BBB
50
Metoclopramide SEs (2)
Oculogyric crisis esp in young women and QTc prolongation
51
The standard dose of ibuprofen
400mg 8hrly
52
Max daily dose of paracetamol
1g up to 6hrly i.e. 4g in 24hrs
53
Max daily dose of codeine
30mg up to 6hrly i.e. 120mg in 24hrs
54
Max daily dose of morphine
10mg up to 6hrly i.e. 40mg in 24hrs
55
What is the morphine breakthrough dose?
1/6th Daily Dose prn
56
What are the SEs of opioids?
Expected: constipation (laxatives), nausea (antiemetics), drowsiness (consider other causes) Toxicity: confusion, hallucinations, itch, myoclonic jerks, pinpoint pupils, resp depression, coma
57
Both PO: Codeine/Tramadol -\> Morphine
Divide by 10
58
Both PO: Morphine -\> Oxycodone
Divide by 1.5
59
Oral Morphine -\> S/C Morphine
Divide by 2
60
Oral Oxycodone -\> S/C Oxycodone
Divide by 2
61
Oral Morphine -\> S/C Diamorphine
Divide by 3
62
Oral Morphine -\> S/C Alfentanil
Divide by 30
63
Oral Morphine -\> Fentanyl Patch
60-90mg/24hrs = 25mcg/hr
64
How often can you change the fentanyl patch?
Every 72hrs or 48hrs under palliative care advice
65
How long does it take fentanyl patches to have an effect?
At least 24hrs so cont other opioids 8-12hrs after starting the patch
66
When is buccal/sublingual fentanyl started?
Used for predictable pain alongside other opioids, have to be on minimum 60mg morphine /day, only licensed to start on lowest dose and work up, max four doses /day, the different brands are not interchangeable
67
What opioid do you use if they’re eGFR impaired?
Switch to oxycodone if 30-60 and stop long acting preparations if \<30 Plus alfentanil and fentanyl are NOT renally excreted
68
Preferred analgesia in renal colic pts w dose
IM Diclofenac 75mg Can cause hepatitis⚠️
69
Which analgesia is first line in neuropathic pain?
Amitriptyline PO 10mg nightly Pregabalin PO 75mg 12hrly
70
Which analgesia do you use in painful diabetic neuropathy?
Duloxetine
71
Tx of Parkinsons
1 - Levodopa w dopa decarboxylase inhibitor 2 - Ropinirole (dopamine agonist) OR Rasagiline (MAOI)
72
Give three examples of non ergot derived dopamine agonists
Ropinirole, rotigotine, pramipexole
73
Important parameter to monitor in pts on digoxin
Serum creatinine as it is mainly excreted renally
74
Important parameter to check @ baseline and monitor in pts on na valproate
LFTs as a/w hepatotoxicity
75
Dose of statin use in 1° and 2° prevention of CVD
1° - 20mg Atorvastatin 2° - 80mg Atorvastatin
76
What is rosuvastatin more likely to cause and why?
Statin-induced myopathy because it is more potent
77
Statin-induced myopathy POA
Check their CK, if \> x5 upper limit stop, if \< x5 monitor and stop is sx become intolerable
78
Statin SEs (3)
Myalgia, abdo pain, rhabdomyolysis NB: it incs ALT/AST
79
Which abx interacts w statins?
Clarithromycin - CYP3A4 inhibitor - stop statins during the course
80
Which diabetes drug interacts w simvastatin?
Gemfibrozil
81
Simvastatin + Gemfibrozil
Myotoxicity
82
When do you review pts on statins?
After 3m to measure total cholesterol, LDL, HDL
83
What is the aim for non-HDL cholesterol after 3m of statins?
\>40% reduction and if not then discuss adherence/inc dose
84
At what GFR can metformin not be used?
GFR \<30ml/min
85
Metformin SEs (2)
GI upset and lactic acidosis
86
First line diabetic med in CKD pts
Gliclazide
87
Diabetes meds that cause hypoglycaemia (3)
Insulin Sulphonylureas Thiazolidinediones
88
Give an example of sulphonylurea
Gliclazide
89
Give an example of thiazolidinediones
Pioglitazone
90
How should you change the usual dose of insulin in type 1 diabetic if BM deranged due to steroids?
Inc insulin dose by 10%
91
Pt w DKA what serum potassium warrants giving fluids w KCl?
3.5-5.5mmol/l use 0.9% saline w 40mmol/l KCl and monitor w an ECG
92
How many mmol/l of NaCl are in 1L of 0.9% saline?
154mmol/l
93
How many mmol of KCl are in 1L of 0.3% potassium?
40mmol/l
94
Max rate at which fluids containing potassium can be given through a peripheral cannula?
10mmol/hr (if above 20 requires cardiac monitoring)
95
Seizures tx w na valproate
Generalised Absence Myoclonic Tonic
96
Seizure tx w ethosuximide
Absence
97
Mild CAP w/o penicillin allergy
Amoxicillin 500mg TDS for 5d
98
Mild CAP w penicillin allergy
Clarithromycin 500mg BD for 5d
99
Clarithromycin + Warfarin
Inc effect of warfarin leading to a rise in INR
100
HAP
IV Tazocin 4.5g TDS
101
What makes up tazocin?
Piperacillin + Tazobactam
102
What should you coprescribe to pts who develop pneumonia after influenza?
Fluclox to cover staph aureus
103
Tx for cellulitis w doses
1 - oral fluclox 250-500mg QDS 2 - oral clarithromycin 250-500mg BD
104
The three C’s causing c. difficile colitis
Cephalosporins Clindamycin Ciprofloxacin
105
Tx of c. difficile colitis
Oral metronidazole 400mg every 8h for 10-14d NB: oral vancomycin is second line
106
All anti-proliferative agents SEs (3)
BM suppression, malignancy, teratogenic
107
Cyclophosphamide SEs (3)
Hair loss, sterility, haemorrhagic cystitis
108
Mycophenolate Mofetil SEs (2)
Herpes and PML
109
Azathioprine SEs (2)
Hepatotoxicity and neutropenia esp if TPMT polymorphism
110
Methotrexate SEs (3)
Hepatotoxicity, pulmonary fibrosis, folate def
111
How long should you wait after stopping MTX before conceiving?
3m BOTH men+women
112
Tacrolimus + Cyclosporin MOA
Inhibit calcineurin which activates IL-2 and hence reduces T cell proliferation
113
Tacrolimus SEs (3)
Nephrotoxic, HTN, neurotoxic
114
Cyclosporin SEs (5)
Same as tacrolimus PLUS dysmorphism and gum hypertrophy
115
Mx of hyperK
Stop any sources of potassium, high flow O2, ECG If ECG changes: 10mL of 10% calcium gluconate 50mL of 50% dextrose w 10U insulin 5mg nebs salbutamol Worth considering: Oral calcium resonium or Lokelma w aperient but takes \>24h
116
When do you measure potassium after dextrose/insulin?
After 4hrs then repeat tx if still high
117
What are aperients?
Drugs to relieve constipation
118
How many mmol of glucose are in 1L of 5% dextrose?
278mmol/l
119
When are dextrose solutions contraindicated?
Stroke due to risk of cerebral oedema
120
What should you beware of w someone on carbimazole?
Neutropenia therefore check FBC regularly w TFTs
121
What drugs cannot be given to asthmatics? (3)
Beta blockers, NSAIDs, adenosine
122
CI of Gentamicin
Myasthenia Gravis
123
Drugs that cause hypoNa (6)
ACEi, diuretics, heparin, antidepressants, antipsychotics, carbamazepine
124
Drugs that cause hyperK (3)
Ramipril, Dalteparin, Tacrolimus
125
CI of Nitrofurantoin
eGRF \<45
126
What drugs can cause your vision to change colour?
Digoxin - Green/Yellow | Sildenafil - Blue
127
Tx of TB SEs
Rifampicin - hepatotoxicity, drug interactions, orange secretions Isoniazid - hepatotoxicity and peripheral neuropathy Pyrazinamide - hepatotoxicity and hyperuricaemia Ethambutol - optic neuritis and visual disturbances
128
Abx for Chlamydia
1. PO Doxycycline 100mg BD 7/7 2. PO Azithromycin 1g STAT -\> 500mg OD 2/7
129
Abx for Gonorrhoea
1. IM Ceftriaxone 250mg single dose 2. PO Cefixime 400mg single dose
130
What drug can lower triglyceride levels?
Fenofibrate
131
What do you give a known T1DM found unconscious?
Rapid IV of 50ml 20% Glucose
132
Which diabetic drug is most likely to cause sig hypo?
Gliclazide
133
Which diabetic drug is most effective at managing post prandial hyperglycaemia?
Acarbose
134
How long do you wait before starting enoxaparin following a stroke?
2m
135
Which classes of abx inhibit cell wall synthesis? (2)
Beta Lactams (penicillins, cephalosporins, carbapenems) and Glycopeptides
136
Which abx causes red man syndrome?
Vancomycin
137
Which classes of abx inhibit protein synthesis? (5)
Aminoglycosides Tetracyclines Macrolides Chloramphenicol Oxazolidinones
138
Which abx causes grey baby syndrome?
Chloramphenicol
139
Which classes of abx inhibit DNA synthesis? (2)
Fluoroquinolones and Nitroimidazoles
140
Which classes of abx inhibit folate metabolism? (2)
Sulphonamides and Diaminopyrimidines
141
What time of day do you give ACEi and why?
At night because of the risk of orthostatic hypotension
142
What do you restart warfain following a raised INR?
\<5
143
Route + Dose of Mg Sulphate
IV 2g over 20 mins
144
What monitoring is required for pts on leviteracetam?
None
145
Beta blocker OD tx
1. Atropine 2. Glucagon
146
Drugs causing malignant hyperthermia (2)
Halothane and Suxamethonium
147
Drug to tx malignant hyperthermia
Dantrolene
148
When would you NOT prescribe 1g \> 0.5g of paracetamol QDS? (2)
Pt weighs less than 40kg or has liver failure
149
Tramadol SEs
Drowsiness + Hallucinations
150
Codeine SE + Tx
Constipation: co prescribe senna
151
Morphine SE + Tx
N+V: co prescribe metoclopramide
152
What is the short and long acting morphine?
Short: oromorph 5-10mg every 4hrs as required Long: morphine sulphate contin 20mg every 12hrs regular
153
What is the short and long acting oxycodone?
Short: endone 2.5-5mg every 4hrs as required Long: oxycontin 10mg every 12hrs regular
154
The WHO pain ladder
1. Nonopioids + NSAIDs which continue throughout the steps 2. Weak Opioid 3. Strong Opioid 4. Nerve Block, Epidurals, PCA Pump
155
What do you need to bare in mind when prescribing morphine? (5)
Start low and go slow, keep in monitored area esp RR, co prescribe antiemetics/laxatives, advise about driving/machinery, avoid alcohol/benzos
156
Anticoag vs Antipl
Relates to Virchows Triad Anticoag: stasis, DVT/PE/AF, activation of clotting factors - heparin, rivaroxaban, warfarin Antipl: vessel wall injury, MI/Stroke, activation of platelets - aspirin, clopidogrel, ticagrelor
157
Which anticoag is preferred in cancer pts?
LMWH
158
What comp do you need to monitor pts for on LMWH?
HIT: heparin induced thrombocytopenia
159
Which anticoag is preferred in renal failure?
Unfractionated Heparin
160
What carries a lower risk of HIT than LMWH or unfractionated heparin?
Fondaparinux
161
What is preferred for stable pts w a provoked DVT?
DOACs
162
How would you counsel a pt starting rivaroxaban?
Switch COCP to alternative form if provoked DVT Advise they may bruise easily and have nosebleeds Safety net that any prolonged bleed or head injury should go to A+E They’ll be on for 3m if provoked, 3-6m if unprovoked, lifelong if recurrent
163
How do you initiate warfarin? (3)
Based off local protocol but generally: check baseline clotting, bridge w heparin for \>=5d, have an outpatient F/U plan w local anticoag service
164
How would you counsel a pt starting warfarin?
Use the yellow book: refer to clinic, blood test appointment, alert card, avoid grapefruit juice
165
How do you tx arterial thrombi?
Start IV heparin bolus then weight based infusion rate checking APTT every 4-6hrs
166
When do you take simvastatin?
ON ie once nightly
167
How do you monitor tx response for pneumonia?
CRP
168
How do you monitor tx response for polyrheumatica myalgia?
Muscle Weakness
169
What is the main drug that causes acute pancreatitis?
Azathioprine
170
Which class of drugs predisposes you to gout?
Thiazide Diuretics
171
What AED must you NOT use in women of childbearing age?
Sodium Valproate
172
How long before trying to get pregnant should you stop methotrexate?
3m
173
The four processes of pharmacokinetics
Absorption
Distribution
Metabolism
Elimination
174
The four parameters of pharmacokinetics
Bioavailability
Volume of Distribution
Half Life
Clearance
175
Why does propranolol cause nightmares but atenolol doesn’t?
It’s lipid soluble and can therefore cross the BBB
176
How do drugs move across cell barriers?
Transcellular - drug - lipid solubility
Paracellular - tissue - gaps b/w cells
NB: drug size affects both
177
At which molecular weight will everything move freely into the filtrate in the glomerulus?
<5000MW
178
How does ethanol cross the BBB despite being water soluble?
It’s ~x10 smaller than most drugs
179
Which part of the kidney has the tightest cell layer?
DCT
180
Def of bioavailability
% of drug that reaches systemic circulation
NB: trick q all IV drugs have 100%
181
Reasons for dec bioavailability of oral drugs
Absorption (lipid solubility, gaps b/w cells, drug size), gut transit time, first pass metabolism
182
What does oral bioavailability equal?
AUC(Oral) / AUC(IV)
NB: AUC - area under curve
183
What does volume of distribution equal?
Dose Administered / Plasma Conc
184
Which values of distribution show where the drug has gone?
3L - Plasma
6L - Blood
42L - Total Body Water
5,000L - Tissue Bound
185
Why is volume of distribution helpful?
Shows you where the drug goes, guides dosing, half life
186
Which drugs are trapped and eliminated in urine?
Water soluble drugs
187
Which drugs would you stop if pts renal function deteriorates?
Water soluble drugs e.g. Digoxin & Metformin
188
How does the body eliminate lipophilic drugs?
The liver metabolises it into a hydrophilic component(s) e.g. phenobarbital
189
What are the two types of metabolism reactions?
Phase 1 -redox/hydrolysis - involves CYP enzymes
Phase 2 - conjugation reactions - does NOT involve CYP enzymes
190
How many enzymes are in the CYP family?
57
191
How do CYP enzymes vary?
Hugely b/w people and from day to day
Genetic - primary structure - different isoforms eiter inc/dec activity
Environment - affects amount - age, sex, smoking, disease, food
192
When does CYP variation matter?
If the drug is only metabolised almost exclusively by one or two e.g. Verapamil & CYP3A4, rifampicin induces, verapamil conc drops by 90%
193
Enzyme Inducers
```
St Johns Wort
Barbiturates
Ethanol
AEDs
Rifampicin
```
194
Enzyme Inhibitors
Grapefruit Juice
Antibiotics
Antifungals
Amiodarone
195
Enzyme Substrates i.e. important drugs that are affected
```
Warfarin
Phenytoin
Theophylline
OCP
Ciclosporin
```
196
Which abx are enzyme inhibitors?
```
Macrolides
Metronidazole
Quinolones
Chloramphenicol
Clarithromycin
```
197
What is the most common junior doc drug interaction?
Clarithromycin & Warfarin
198
What is plug hole/first order kinetics?
The amount eliminated is proportional to drug conc e.g. most drugs
k[Drug]^1
199
What is bucket/zero order kinetics?
The amount eliminated is constant regardless of drug conc e.g. Ethanol & Phenytoin
k[Drug]^0
200
Plasma Vs Biological Half Life
Amount of time requires for plasma drug conc vs biological effect of the drug to halve
201
Which half life is more important?
Biological
202
What is the biological half life of aspirin?
Hrs - pyrexia
Days - pl inhibition
203
What causes a long half life?
High volume of distribution +/or low clearance
204
What is the clearance of Cr?
125mL/min
205
What is the volume of distribution of amlodipine?
20L/kg
206
What is the volume of distribution of nifedipine?
1L/kg
207
Why is a loading dose often required?
To eventually reach the point at which the amount you’re infusing = eliminating
208
How many half lives does it take to reach the steady state?
~5
209
What do you do if the dose is subtherapeutic?
Ask before just inc daily dose
210
What should you always document alongside O2 sats?
Whether the pt is on room air or inspired O2
211
What should you do before testing cap refill?
Hold the hand above the level of the heart for 5s
212
What is included in the D of A-E approach?
Pupils, GCS (E4, V5, M6), temp, BM, drugs
213
What are the six parameters of the NEWS score?
RR, O2 sats, temp, SBP, HR, consciousness
214
What is a normal NEWS score?
Zero
215
What does the NEWS score show?
Flags early pts who are at risk of deterioration: agg 0-3 low, individual parameter scoring 3 or agg 5-6 medium, agg 7+ high
216
Rank the following problem list: hypotension, pain, infection, hyperglycaemia
1. Hypotension
2. Pain
3. Infection
4. Hyperglycaemia
217
How does hyperglycaemia make the prev problems worse?
Dehydration and poor wound healing
218
What should you write instead of normal saline?
0.9% sodium chloride
Resus - 500mL, IV, over 30m
Mainten - 1L, IV, over 8hrs
219
List examples of the drugs along the analgesic ladder
1. Mild - paracetamol and NSAIDs
2. Mod - codeine, co-codamol, dihydrocodeine, co-dydramol, tramadol, tramacet, BuTrans
3. Sev - oramorph, MST, oxycodone, fentanyl
220
What should you document for the pulse?
Both the rate and the rhythm
221
What do you assume if the ulcer probes to bone?
Osteomyelitis
222
What could cause low BP?
Poor oral intake, osmotic diuresis, sepsis
223
When would HbA1c not be valid?
Haemoglobinopathies, rapid red cell turnover, sig renal failure
224
At what eGFR should you avoid using NSAIDs and metformin?
<30mL/min
225
What should you check if a T2DM comes through casualty on metformin?
How unwell they are, any evidence of pulm oedema, eGFR
226
When should you stop the sliding scale/VRII?
When the pt is eating/drinking to avoid the hrly finger prick testing
227
Which heparin do you give if the eGFR <30mL/min?
Switch to s/c unfractionated 5000U BD
228
What do you give for VTE prophylaxis?
LMWH s/c enoxaparin 40mg OD + TED stockings
229
Which drugs are having an AKI a red flag for?
Ramipril, Metformin, LMWH
230
What is the hallmark of insulin def?
Ketones
231
What is the quantitive value of abnormal and significant blood ketones?
>0.6 Abnormal
| >1.5 Significant
232
What is C-peptide a marker of?
Endogenous insulin production
233
What is hypoglycaemia defined as?
Make 4 the Floor
Most likely a result of sulphonylureas and insulin - need to make sure type ones are hypo aware
Adrenergic sympathetic activation: pallor, sweating, tachycardia, palps, tremor, lip tingling, anxiety
Neuroglycopenic insufficient glucose to fuel brain: confusion, seizure
Sweating, confusion, dizziness, tachycardia, aggression, irritability, tremor, drowsiness
234
What’s important to know before treating a pt’s hypoglycaemia?
Oral vs Parenteral: conscious, confused, swallow
Y/N/Y: orange juice from the trolley and F/U w slow release CHO snack
Y/Y/N: A-E then if access IV 100ml 20% dextrose or if no access IM 1mg glucagon and establish IV access
Recheck BM in 15mins, establish why the hypo happened, document
235
When would you not use IM glucagon?
Malnutrition + Chronic Liver Disease
236
What can predispose to a high BM in hospital?
Sepsis
Immobility
Food Choices
Incorrect Insulin
237
Workup for High BM
Confirm BM, check blood ketones, check what he’s been eating
Correction dose ie 1-2 extra units of short acting insulin
If basal insulin missed and raised ketones, check venous ph and HCO3
If acidotic tx for DKA w fixed rate hrly IV insulin and fluids
If normal pH, but not eating and drinking, give the missed s/c insulin and start VRII w IV fluids until able to eat and drink again
If physiological response to sugary drink and normal ketones T1DM correction novrapid if T2DM let it drift back down to avoid a hypo
238
Pain: Nociceptive vs Neuropathic
Nociceptive: somatic or visceral a/w tissue injury
Neuropathic: PNS or CNS a/w nerve injury
239
What are other causes of pain in cancer pts aside from the cancer itself?
Anticancer tx (mucositis), related debility (constipation), concurrent disorder (OA)
240
What are examples of weak and strong opiates?
Weak: codeine, tramadol, buprenorphine
Strong: morphine, oxycodone, diamorphine, alfentanil, fentanyl
241
What are the different doses of co-codamol?
They come as 8/500, 15/500, 30/500 w the first being codeine in mg alongside a fixed amount of paracetamol thus capping the daily dose to 8 tabs ie 4g of paracetamol
242
What are the different morphine preparations?
Immediate release: liquid oramorph (10mg/5mls or 20mg/1ml) and sevredol tabs (10, 20, 50mg)
Sustained release: MST 12hrly and MXL 24hrly
243
What are the exceptions to the general rule of not mixing opioids?
You can give prn oxycodone for break through w diamorphine, alfentanil, fentanyl
244
What should the pt be counselled on regarding opioid use and driving?
It will impair their ability so: no driving within 4hrs of immediate release prep, 48hrs of dose change, if taken benzos or alcohol alongside
245
What is the total body fluid of a 70kg adult?
42L
246
How is total body fluid split up?
IC 28L + EC 14L of which 9L is interstitial and 5L is intravascular ie 2/3 IC vs 1/3 EV and 2/3 interstitial vs 1/3 intravascular
247
Which membranes separate IC vs EC and interstitial vs intravascular?
Cell + Capillary
248
How do the cell membranes affect how the equilibrium is kept?
Cell: active and passive processes
Capillary: hydrostatic and oncotic pressures
249
What are the daily requirements of fluids + electrolytes according to NICE?
25-30ml/kg/day of H2O
1mmol/kg/day of Na, K, Cl
50-100g/day of glucose regardless of weight to prevent ketosis +/- TPN
250
What are the two main types of IV fluids?
Crystalloids: 0.9% Sodium Chloride, Hartmann’s, Dextrose
Colloids: Albumin + Gelofusine
251
What are the 5R’s of giving fluid?
```
Resus
Replace
Routine
Redistribution
Reassessment
```
252
Which bag of fluid can you add potassium to?
0.9% Sodium Chloride: usually comes premixed and can give more per litre in ICU
253
What is the problem w prescribing too much 0.9% NaCl?
Hyperchloraemic Met Acidosis: inc Cl and dec HCO3
254
How would you assess fluid balance?
Overload: raised JVP, pulm oedema, sacral/peripheral oedema
Deplete: dry mucous membranes, red skin turgor, sunken eyes, inc CRT, tachycardic, hypotensive
255
What are insensible losses?
Inc daily requirements: if the pt is septic ie febrile and tachycardic, on NIV/tachypnoeic, inc bowel output eg stoma/diarrhoea, burns victim
256
What imbalances does D+V create?
D: low K and acidosis
V: low KCl and alkalosis
257
What is the composition of the crystalloids?
0.9% Sodium Chloride: 154 Na, 154 Cl, 300 OsmolaLity
Hartmann’s: 131 Na, 111 Cl, 5 K, 4 Ca, 29 HCO3, 281 OsmolaLity
5% Dextrose: 50g Dextrose + 278 OsmolaLity
258
What is the bicarbonate in Hartmann’s present as in the bag?
Lactate -[Liver]-> Bicarbonate
Therefore if the pt is septic it’ll make serial lactate measurements difficult to interpret
259
Which fluid should NOT be used for resus?
Dextrose: it’s hypotonic so will be rapidly taken up into cells
260
What is the classic maintenance fluid regime?
One Salty + Two Sweet: 0.5/1L Sodium Chloride w 40mmol KCl + 1L 5% Dextrose
261
What is the max rate of potassium on a non monitored ward?
10mmol/hr
262
What is the max rate of an electric fluids pump?
1500ml/hr = 500ml/20mins
263
Who should you AVOID giving Hartmann’s to?
Pts who are/at risk of hyperK
264
What is the Holliday-Segar formula for calculating maintenance fluids in children?
100ml/kg/day for first 10kg
50ml/kg/day for second 10kg
20ml/kg/day for every kg after
265
What is the fluid requirement for a child in DKA?
Resus: usually 20ml/kg except in DKA, cardiac problems, trauma 10ml/kg
Replacement:
W/o Shock 5%
With Shock 10%
Maintenance:
<10kg: 2ml/kg/hr
10-40kg: 1ml/kg/hr
>40kg: 40ml/hr
266
What is an earlier sign than a drop in BP for dehydration?
Tachycardia
267
Why is your serum potassium a poor reflection of total body potassium?
The vast majority is in the cells
268
What is the fail safe first bag of maintenance?
1L Sodium Chloride w 40mmol KCl over 8hrs
Unless low BW then think about 1L 5% Dextrose instead and if elderly over a longer time period
269
When would you put more potassium in fluids?
If the pt is deficient or on fixed rate insulin
270
Def of High Output Stoma
>1L/day x3 or >2L/day x2
271
What are the causes and effects of a high output stoma?
It’s a new stoma, short bowel syndrome, sepsis, incomplete obstruction, prokinetics
272
What are the effects of a high output stoma?
Dehydration and AKI, low Na/Mg/B12, wt loss
273
Mx of High Output Stoma
Resus, check and replace electrolytes, strict fluid balance, tx underlying cause, dietitian review
1. Dietary Measures
2. Loperamide/Omeprazole
3. Dbl Strength Dioralyte/Lansoprazole
3. Codeine
274
What are the different MOA for contraception?
COCP - inhibits ovulation POP - thickens cervical mucus Depot/Implant - both of above IUS - prevents endometrial proliferation IUD - dec sperm motility and survival
275
What are the UKMEC4 for the CHC?
Age \>=35 AND smoking \>=15 cigarettes/day Postpartum: other VTE RF b/w 0-3wks OR breast feeding b/w 0-6wks Others: \>=160/100 BP, vascular disease, IHD, stroke, AF, VTE, known thrombogenic mutation, positive antiphospholipid abs, major surgery w prolonged immobilisation, migraine w aura, current breast cancer, HCA/HCC, decompensated liver cirrhosis
276
What cancers are at inc/dec risk w the COCP?
Inc: breast + cervical Dec: ovarian, endometrial, colorectal
277
When should the mirena be inserted?
Day 1-7 of the menstrual cycle and only if there’s reasonable certainty that the woman is not currently pregnant: if UPSI must take a preg test @ 3wks
278
What should you advise before the removal or the mirena?
Use barrier methods/avoid intercourse for 7d prior to removal
279
When should a woman w the mirena seek medical advice?
If menstrual abnormalities persist beyond 6m, any lower abdo pain fever discharge, believes she is preg
280
What are the types of long acting contraception?
Reversible: depot, implant, IUS/IUD Non-Reversible: sterilisation
281
What are the four UKMEC categories?
1: No Restriction 2: Adv \> Dis 3: Dis \> Adv 4: Absolute CI
282
What is the PEARL index?
Risk of pregnancy per 100 women yrs ie no of women out of 100 who would fall preg per year
283
What are the different methods of emerg contraception?
Levonorgestrel/Levonelle/LNG: within 72h, inhibits ovulation, SEs nausea dizziness fatigue, CI if porphyria or enzyme inducers Ulipristal/ellaOne/UPA: within 120h, inhibits ovulation, SEs above plus back pain myalgia mood disorders, CI if \<18yrs sev asthma enzyme inducers Copper IUD: within 5d of UPSI or calculated ovulation, inhibits fertilisation and implantation, ideal if breastfeeding, CI if current PID cervical/endometrial cancer cu allergy
284
What are the risks of the copper IUD?
Expulsion: 1/20 Uterine Perforation: 2/1000
285
What is the most effective form of emerg contraception?
Copper IUD
286
What is the most effective type of any contraception?
Implant
287
What is the best LARC of choice for young pts?
Progesterone only implant as the IUS/IUD are UKMEC2 for women \<20yrs
288
When can the mirena and copper IUD start being relied upon?
Mirena: after seven days Copper IUD: immediately
289
Which types of contraception are unaffected by AEDs?
Depot, Mirena, Copper IUD
290
What should you do if you miss one COCP?
Take the last pill even if it means taking two pills in one day and then continue as normal
291
What should you do if you miss two COCP?
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills, use condoms/abstain for 7d: if day 1-7 also emerg contraception vs day 15-21 omit the pill free week
292
What should you do if the change of COCP patch is delayed at the end of wk1 or wk 2 by \>48hrs?
Start barrier method for 7d and consider emerg if UPSI was in the last 5d
293
What should you do if the removal of COCP patch is delayed at the end of wk3?
Remove asap and then use the next patch on the usual start day even if withdrawal bleeding is still occurring
294
What is the LAM?
1. Postpartum \<6m 2. Fully Breastfed 3. Amenorrheic
295
When do women require contraception after birth who do not meet LAM criteria?
Day 21: if starting COCP use condoms for 7d vs POP use condoms for 2d
296
When can an IUS/IUD be inserted following childbirth?
Within 48hrs or after 4wks
297
When should pts who have taken the emerg pill come back?
If they vomited \<2hrs to repeat the dose
298
How does the pts BMI/wt impact the choice of morning after pill?
If BMI\>26 or wt\>70 give double dose LNG or UPA
299
What are the progestogen SEs?
Nausea Headache Breast Pain
300
What are The Fraser Guidelines?
They understand, cannot be persuaded to inform parents, likely to begin/continue UPSI, unless they receive contraception their physical/mental health are likely to suffer, best interests
301
What red the efficacy of the COCP?
Vomiting within 2hrs of taking a pill + medications that induce diarrhoea/enzyme inducers
302
What are the estradiol SEs?
GI Discomfort + Wt Changes
303
How long does it take the POP to have an affect?
If first five days of cycle immediate otherwise 2d
304
What should you do if you miss one POP?
If \<3h continue as normal vs \>3h (or 12h if cerazette) take asap and use barrier method for 2d
305
When can/do you stop contraception?
Women \<50: stop \>=2yrs amenorrhoea + continue COCP/depo until 50 Women \>50: stop \>=1yr amenorrhoea + switch COCP/depo to POP/non-hormonal
306
Which form of combined contraception does NOT inc your risk of clots?
Transdermal Patch
307
How long may it take fertility to return after the depo?
6-12m
308
When is laparoscopic sterilisation affective?
From the first period
