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Year 6 - PSA > PSA: Intro Week > Flashcards

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

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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)

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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?

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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

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5
Q

P450 inhibitors w warfarin

A

Both inc INR so may need to reduce warfarin dose

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6
Q

List the P450 inducers

A

PCC SSBAR Phenytoin Carbamazepine Cigarettes St Johns Wort Sulphonylureas Barbiturates Alcohol (Chronic) Rifampicin

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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

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8
Q

Which contraceptives are unaffected by EIDs?

A

Depo, mirena, copper iud

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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

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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

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11
Q

Drugs to stop before surgery

A

I LACK OP Insulin Lithium Anticoags/Antipl COCP/HRT K Sparing Diuretics Oral Hypoglycaemics Perindopril/ACEi

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12
Q

When do you stop COCP/HRT before surgery?

A

4w

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13
Q

When do you stop aspirin before surgery?

A

1w

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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

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15
Q

What do you do if INR >1.5 on the day before surgery?

A

Give 1-5mg vitamin K PO

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16
Q

When do you stop lithium before surgery?

A

The day before

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17
Q

When do you stop K sparing diuretics and Perindopril/ACEi before surgery?

A

On the day

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18
Q

Which drug do you inc for surgery?

A

Steroids

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19
Q

Aspirin SEs (3)

A

Haemorrhage, peptic ulcers, tinnitus

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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

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21
Q

Blood clot prophylaxis

A

LMWH + TED stockings

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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

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23
Q

How many units is 40mg enoxaparin?

A

4000U

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24
Q

Alternative to LMWH in pts w VTE and needle phobia including dose

A

Apixaban 10mg BD for 7d

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25
Q

The CI to TED stockings

A

Peripheral arterial disease due to the risk of ALI

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26
Q

Anti-HTN SE

A

Postural hypotension therefore tend to take in the evening/night

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27
Q

What does midodrine tx? (2)

A

Dysautonomia and orthostatic hypotension

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28
Q

Which drugs inc risk of renal damage? (2)

A

ACEi and NSAIDs except aspirin

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29
Q

Why does red angiotensin-II lead to acute RF?

A

No efferent arteriole constriction when GFR reduces

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30
Q

Starting dose of ACEi in Hf pts

A

Ramipril 1.25mg OD Lisinopril/Enalapril 2.5mg OD

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31
Q

ACEi SEs (4)

A

Dry cough (inc bradykinin), acute RF (red Ang-II), hyperK (red aldosterone) and angioedema if AfroCaribbean pts

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32
Q

Beta-blocker SEs (3)

A

Bradycardia, wheeze, worsens acute HF

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33
Q

Drugs to avoid in pts w peripheral vascular disease (2)

A

ACEi and beta blockers

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34
Q

Dose of amlodipine used for HTN

A

5-10mg OD

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35
Q

Dose of verapamil used for rate control in AF

A

40mg 8hrly

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36
Q

Which factor X inhibitor can be used in AF?

A

Rivaroxaban 20mg OD w food

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37
Q

CCB SEs (3)

A

Bradycardia, peripheral oedema, flushing Plus verapamil causes constipation

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38
Q

Drugs causing ankle oedema (2)

A

CCBs and Naproxen

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39
Q

Digoxin SEs (6)

A

N+V, diarrhoea, blurred vision, confusion, drowsiness, xanthopsia

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40
Q

Diuretic SE

A

Hypoperfusion leads to RF

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41
Q

Frusemide SE

A

Gout

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42
Q

Spironolactone SE

A

Gynaecomastia

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43
Q

Which anti-HTNs cause hypoK? (2)

A

Loop diuretics and thiazides

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44
Q

What should be checked and corrected before starting amiodarone?

A

Serum potassium as it can cause hypoK

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45
Q

Antiemetics MOA

A

Antagonists to: H1 - Cyclizine DA - Phenothiazines DA2 - Metoclopramide & Domperidone 5HT3 - Ondansetron

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46
Q

Dose of cyclizine

A

PO/IV/IM 50mg 8hrly

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47
Q

When should you avoid using cyclizine?

A

Heart failure pts

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48
Q

Dose of metoclopramide

A

PO/IV/IM 10mg 8hrly

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49
Q

When should you avoid using metoclopramide?

A

Parkinsons pts & GI onstr/perf/haem NB: domperidone is safe in parkinsons because it doesn’t cross the BBB

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50
Q

Metoclopramide SEs (2)

A

Oculogyric crisis esp in young women and QTc prolongation

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51
Q

The standard dose of ibuprofen

A

400mg 8hrly

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52
Q

Max daily dose of paracetamol

A

1g up to 6hrly i.e. 4g in 24hrs

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53
Q

Max daily dose of codeine

A

30mg up to 6hrly i.e. 120mg in 24hrs

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54
Q

Max daily dose of morphine

A

10mg up to 6hrly i.e. 40mg in 24hrs

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55
Q

What is the morphine breakthrough dose?

A

1/6th Daily Dose prn

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56
Q

What are the SEs of opioids?

A

Expected: constipation (laxatives), nausea (antiemetics), drowsiness (consider other causes) Toxicity: confusion, hallucinations, itch, myoclonic jerks, pinpoint pupils, resp depression, coma

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57
Q

Both PO: Codeine/Tramadol -> Morphine

A

Divide by 10

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58
Q

Both PO: Morphine -> Oxycodone

A

Divide by 1.5

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59
Q

Oral Morphine -> S/C Morphine

A

Divide by 2

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60
Q

Oral Oxycodone -> S/C Oxycodone

A

Divide by 2

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61
Q

Oral Morphine -> S/C Diamorphine

A

Divide by 3

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62
Q

Oral Morphine -> S/C Alfentanil

A

Divide by 30

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63
Q

Oral Morphine -> Fentanyl Patch

A

60-90mg/24hrs = 25mcg/hr

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64
Q

How often can you change the fentanyl patch?

A

Every 72hrs or 48hrs under palliative care advice

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65
Q

How long does it take fentanyl patches to have an effect?

A

At least 24hrs so cont other opioids 8-12hrs after starting the patch

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66
Q

When is buccal/sublingual fentanyl started?

A

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

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67
Q

What opioid do you use if they’re eGFR impaired?

A

Switch to oxycodone if 30-60 and stop long acting preparations if <30 Plus alfentanil and fentanyl are NOT renally excreted

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68
Q

Preferred analgesia in renal colic pts w dose

A

IM Diclofenac 75mg Can cause hepatitis⚠️

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69
Q

Which analgesia is first line in neuropathic pain?

A

Amitriptyline PO 10mg nightly Pregabalin PO 75mg 12hrly

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70
Q

Which analgesia do you use in painful diabetic neuropathy?

A

Duloxetine

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71
Q

Tx of Parkinsons

A

1 - Levodopa w dopa decarboxylase inhibitor 2 - Ropinirole (dopamine agonist) OR Rasagiline (MAOI)

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72
Q

Give three examples of non ergot derived dopamine agonists

A

Ropinirole, rotigotine, pramipexole

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73
Q

Important parameter to monitor in pts on digoxin

A

Serum creatinine as it is mainly excreted renally

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74
Q

Important parameter to check @ baseline and monitor in pts on na valproate

A

LFTs as a/w hepatotoxicity

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75
Q

Dose of statin use in 1° and 2° prevention of CVD

A

1° - 20mg Atorvastatin 2° - 80mg Atorvastatin

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76
Q

What is rosuvastatin more likely to cause and why?

A

Statin-induced myopathy because it is more potent

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77
Q

Statin-induced myopathy POA

A

Check their CK, if > x5 upper limit stop, if < x5 monitor and stop is sx become intolerable

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78
Q

Statin SEs (3)

A

Myalgia, abdo pain, rhabdomyolysis NB: it incs ALT/AST

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79
Q

Which abx interacts w statins?

A

Clarithromycin - CYP3A4 inhibitor - stop statins during the course

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80
Q

Which diabetes drug interacts w simvastatin?

A

Gemfibrozil

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81
Q

Simvastatin + Gemfibrozil

A

Myotoxicity

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82
Q

When do you review pts on statins?

A

After 3m to measure total cholesterol, LDL, HDL

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83
Q

What is the aim for non-HDL cholesterol after 3m of statins?

A

>40% reduction and if not then discuss adherence/inc dose

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84
Q

At what GFR can metformin not be used?

A

GFR <30ml/min

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85
Q

Metformin SEs (2)

A

GI upset and lactic acidosis

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86
Q

First line diabetic med in CKD pts

A

Gliclazide

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87
Q

Diabetes meds that cause hypoglycaemia (3)

A

Insulin Sulphonylureas Thiazolidinediones

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88
Q

Give an example of sulphonylurea

A

Gliclazide

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89
Q

Give an example of thiazolidinediones

A

Pioglitazone

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90
Q

How should you change the usual dose of insulin in type 1 diabetic if BM deranged due to steroids?

A

Inc insulin dose by 10%

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91
Q

Pt w DKA what serum potassium warrants giving fluids w KCl?

A

3.5-5.5mmol/l use 0.9% saline w 40mmol/l KCl and monitor w an ECG

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92
Q

How many mmol/l of NaCl are in 1L of 0.9% saline?

A

154mmol/l

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93
Q

How many mmol of KCl are in 1L of 0.3% potassium?

A

40mmol/l

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94
Q

Max rate at which fluids containing potassium can be given through a peripheral cannula?

A

10mmol/hr (if above 20 requires cardiac monitoring)

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95
Q

Seizures tx w na valproate

A

Generalised Absence Myoclonic Tonic

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96
Q

Seizure tx w ethosuximide

A

Absence

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97
Q

Mild CAP w/o penicillin allergy

A

Amoxicillin 500mg TDS for 5d

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98
Q

Mild CAP w penicillin allergy

A

Clarithromycin 500mg BD for 5d

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99
Q

Clarithromycin + Warfarin

A

Inc effect of warfarin leading to a rise in INR

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100
Q

HAP

A

IV Tazocin 4.5g TDS

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101
Q

What makes up tazocin?

A

Piperacillin + Tazobactam

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102
Q

What should you coprescribe to pts who develop pneumonia after influenza?

A

Fluclox to cover staph aureus

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103
Q

Tx for cellulitis w doses

A

1 - oral fluclox 250-500mg QDS 2 - oral clarithromycin 250-500mg BD

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104
Q

The three C’s causing c. difficile colitis

A

Cephalosporins Clindamycin Ciprofloxacin

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105
Q

Tx of c. difficile colitis

A

Oral metronidazole 400mg every 8h for 10-14d NB: oral vancomycin is second line

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106
Q

All anti-proliferative agents SEs (3)

A

BM suppression, malignancy, teratogenic

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107
Q

Cyclophosphamide SEs (3)

A

Hair loss, sterility, haemorrhagic cystitis

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108
Q

Mycophenolate Mofetil SEs (2)

A

Herpes and PML

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109
Q

Azathioprine SEs (2)

A

Hepatotoxicity and neutropenia esp if TPMT polymorphism

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110
Q

Methotrexate SEs (3)

A

Hepatotoxicity, pulmonary fibrosis, folate def

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111
Q

How long should you wait after stopping MTX before conceiving?

A

3m BOTH men+women

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112
Q

Tacrolimus + Cyclosporin MOA

A

Inhibit calcineurin which activates IL-2 and hence reduces T cell proliferation

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113
Q

Tacrolimus SEs (3)

A

Nephrotoxic, HTN, neurotoxic

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114
Q

Cyclosporin SEs (5)

A

Same as tacrolimus PLUS dysmorphism and gum hypertrophy

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115
Q

Mx of hyperK

A

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

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116
Q

When do you measure potassium after dextrose/insulin?

A

After 4hrs then repeat tx if still high

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117
Q

What are aperients?

A

Drugs to relieve constipation

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118
Q

How many mmol of glucose are in 1L of 5% dextrose?

A

278mmol/l

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119
Q

When are dextrose solutions contraindicated?

A

Stroke due to risk of cerebral oedema

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120
Q

What should you beware of w someone on carbimazole?

A

Neutropenia therefore check FBC regularly w TFTs

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121
Q

What drugs cannot be given to asthmatics? (3)

A

Beta blockers, NSAIDs, adenosine

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122
Q

CI of Gentamicin

A

Myasthenia Gravis

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123
Q

Drugs that cause hypoNa (6)

A

ACEi, diuretics, heparin, antidepressants, antipsychotics, carbamazepine

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124
Q

Drugs that cause hyperK (3)

A

Ramipril, Dalteparin, Tacrolimus

125
Q

CI of Nitrofurantoin

A

eGRF <45

126
Q

What drugs can cause your vision to change colour?

A

Digoxin - Green/Yellow | Sildenafil - Blue

127
Q

Tx of TB SEs

A

Rifampicin - hepatotoxicity, drug interactions, orange secretions Isoniazid - hepatotoxicity and peripheral neuropathy Pyrazinamide - hepatotoxicity and hyperuricaemia Ethambutol - optic neuritis and visual disturbances

128
Q

Abx for Chlamydia

A
  1. PO Doxycycline 100mg BD 7/7 2. PO Azithromycin 1g STAT -> 500mg OD 2/7
129
Q

Abx for Gonorrhoea

A
  1. IM Ceftriaxone 250mg single dose 2. PO Cefixime 400mg single dose
130
Q

What drug can lower triglyceride levels?

A

Fenofibrate

131
Q

What do you give a known T1DM found unconscious?

A

Rapid IV of 50ml 20% Glucose

132
Q

Which diabetic drug is most likely to cause sig hypo?

A

Gliclazide

133
Q

Which diabetic drug is most effective at managing post prandial hyperglycaemia?

A

Acarbose

134
Q

How long do you wait before starting enoxaparin following a stroke?

A

2m

135
Q

Which classes of abx inhibit cell wall synthesis? (2)

A

Beta Lactams (penicillins, cephalosporins, carbapenems) and Glycopeptides

136
Q

Which abx causes red man syndrome?

A

Vancomycin

137
Q

Which classes of abx inhibit protein synthesis? (5)

A

Aminoglycosides Tetracyclines Macrolides Chloramphenicol Oxazolidinones

138
Q

Which abx causes grey baby syndrome?

A

Chloramphenicol

139
Q

Which classes of abx inhibit DNA synthesis? (2)

A

Fluoroquinolones and Nitroimidazoles

140
Q

Which classes of abx inhibit folate metabolism? (2)

A

Sulphonamides and Diaminopyrimidines

141
Q

What time of day do you give ACEi and why?

A

At night because of the risk of orthostatic hypotension

142
Q

What do you restart warfain following a raised INR?

A

<5

143
Q

Route + Dose of Mg Sulphate

A

IV 2g over 20 mins

144
Q

What monitoring is required for pts on leviteracetam?

A

None

145
Q

Beta blocker OD tx

A
  1. Atropine 2. Glucagon
146
Q

Drugs causing malignant hyperthermia (2)

A

Halothane and Suxamethonium

147
Q

Drug to tx malignant hyperthermia

A

Dantrolene

148
Q

When would you NOT prescribe 1g > 0.5g of paracetamol QDS? (2)

A

Pt weighs less than 40kg or has liver failure

149
Q

Tramadol SEs

A

Drowsiness + Hallucinations

150
Q

Codeine SE + Tx

A

Constipation: co prescribe senna

151
Q

Morphine SE + Tx

A

N+V: co prescribe metoclopramide

152
Q

What is the short and long acting morphine?

A

Short: oromorph 5-10mg every 4hrs as required Long: morphine sulphate contin 20mg every 12hrs regular

153
Q

What is the short and long acting oxycodone?

A

Short: endone 2.5-5mg every 4hrs as required Long: oxycontin 10mg every 12hrs regular

154
Q

The WHO pain ladder

A
  1. Nonopioids + NSAIDs which continue throughout the steps 2. Weak Opioid 3. Strong Opioid 4. Nerve Block, Epidurals, PCA Pump
155
Q

What do you need to bare in mind when prescribing morphine? (5)

A

Start low and go slow, keep in monitored area esp RR, co prescribe antiemetics/laxatives, advise about driving/machinery, avoid alcohol/benzos

156
Q

Anticoag vs Antipl

A

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
Q

Which anticoag is preferred in cancer pts?

A

LMWH

158
Q

What comp do you need to monitor pts for on LMWH?

A

HIT: heparin induced thrombocytopenia

159
Q

Which anticoag is preferred in renal failure?

A

Unfractionated Heparin

160
Q

What carries a lower risk of HIT than LMWH or unfractionated heparin?

A

Fondaparinux

161
Q

What is preferred for stable pts w a provoked DVT?

A

DOACs

162
Q

How would you counsel a pt starting rivaroxaban?

A

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
Q

How do you initiate warfarin? (3)

A

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
Q

How would you counsel a pt starting warfarin?

A

Use the yellow book: refer to clinic, blood test appointment, alert card, avoid grapefruit juice

165
Q

How do you tx arterial thrombi?

A

Start IV heparin bolus then weight based infusion rate checking APTT every 4-6hrs

166
Q

When do you take simvastatin?

A

ON ie once nightly

167
Q

How do you monitor tx response for pneumonia?

A

CRP

168
Q

How do you monitor tx response for polyrheumatica myalgia?

A

Muscle Weakness

169
Q

What is the main drug that causes acute pancreatitis?

A

Azathioprine

170
Q

Which class of drugs predisposes you to gout?

A

Thiazide Diuretics

171
Q

What AED must you NOT use in women of childbearing age?

A

Sodium Valproate

172
Q

How long before trying to get pregnant should you stop methotrexate?

A

3m

173
Q

The four processes of pharmacokinetics

A

Absorption
Distribution
Metabolism
Elimination

174
Q

The four parameters of pharmacokinetics

A

Bioavailability
Volume of Distribution
Half Life
Clearance

175
Q

Why does propranolol cause nightmares but atenolol doesn’t?

A

It’s lipid soluble and can therefore cross the BBB

176
Q

How do drugs move across cell barriers?

A

Transcellular - drug - lipid solubility

Paracellular - tissue - gaps b/w cells

NB: drug size affects both

177
Q

At which molecular weight will everything move freely into the filtrate in the glomerulus?

A

<5000MW

178
Q

How does ethanol cross the BBB despite being water soluble?

A

It’s ~x10 smaller than most drugs

179
Q

Which part of the kidney has the tightest cell layer?

A

DCT

180
Q

Def of bioavailability

A

% of drug that reaches systemic circulation

NB: trick q all IV drugs have 100%

181
Q

Reasons for dec bioavailability of oral drugs

A

Absorption (lipid solubility, gaps b/w cells, drug size), gut transit time, first pass metabolism

182
Q

What does oral bioavailability equal?

A

AUC(Oral) / AUC(IV)

NB: AUC - area under curve

183
Q

What does volume of distribution equal?

A

Dose Administered / Plasma Conc

184
Q

Which values of distribution show where the drug has gone?

A

3L - Plasma
6L - Blood
42L - Total Body Water
5,000L - Tissue Bound

185
Q

Why is volume of distribution helpful?

A

Shows you where the drug goes, guides dosing, half life

186
Q

Which drugs are trapped and eliminated in urine?

A

Water soluble drugs

187
Q

Which drugs would you stop if pts renal function deteriorates?

A

Water soluble drugs e.g. Digoxin & Metformin

188
Q

How does the body eliminate lipophilic drugs?

A

The liver metabolises it into a hydrophilic component(s) e.g. phenobarbital

189
Q

What are the two types of metabolism reactions?

A

Phase 1 -redox/hydrolysis - involves CYP enzymes

Phase 2 - conjugation reactions - does NOT involve CYP enzymes

190
Q

How many enzymes are in the CYP family?

A

57

191
Q

How do CYP enzymes vary?

A

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
Q

When does CYP variation matter?

A

If the drug is only metabolised almost exclusively by one or two e.g. Verapamil & CYP3A4, rifampicin induces, verapamil conc drops by 90%

193
Q

Enzyme Inducers

A 
St Johns Wort
Barbiturates
Ethanol
AEDs
Rifampicin
194
Q

Enzyme Inhibitors

A

Grapefruit Juice
Antibiotics
Antifungals
Amiodarone

195
Q

Enzyme Substrates i.e. important drugs that are affected

A 
Warfarin
Phenytoin
Theophylline
OCP
Ciclosporin
196
Q

Which abx are enzyme inhibitors?

A 
Macrolides
Metronidazole
Quinolones
Chloramphenicol
Clarithromycin
197
Q

What is the most common junior doc drug interaction?

A

Clarithromycin & Warfarin

198
Q

What is plug hole/first order kinetics?

A

The amount eliminated is proportional to drug conc e.g. most drugs

k[Drug]^1

199
Q

What is bucket/zero order kinetics?

A

The amount eliminated is constant regardless of drug conc e.g. Ethanol & Phenytoin

k[Drug]^0

200
Q

Plasma Vs Biological Half Life

A

Amount of time requires for plasma drug conc vs biological effect of the drug to halve

201
Q

Which half life is more important?

A

Biological

202
Q

What is the biological half life of aspirin?

A

Hrs - pyrexia

Days - pl inhibition

203
Q

What causes a long half life?

A

High volume of distribution +/or low clearance

204
Q

What is the clearance of Cr?

A

125mL/min

205
Q

What is the volume of distribution of amlodipine?

A

20L/kg

206
Q

What is the volume of distribution of nifedipine?

A

1L/kg

207
Q

Why is a loading dose often required?

A

To eventually reach the point at which the amount you’re infusing = eliminating

208
Q

How many half lives does it take to reach the steady state?

A

~5

209
Q

What do you do if the dose is subtherapeutic?

A

Ask before just inc daily dose

210
Q

What should you always document alongside O2 sats?

A

Whether the pt is on room air or inspired O2

211
Q

What should you do before testing cap refill?

A

Hold the hand above the level of the heart for 5s

212
Q

What is included in the D of A-E approach?

A

Pupils, GCS (E4, V5, M6), temp, BM, drugs

213
Q

What are the six parameters of the NEWS score?

A

RR, O2 sats, temp, SBP, HR, consciousness

214
Q

What is a normal NEWS score?

A

Zero

215
Q

What does the NEWS score show?

A

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
Q

Rank the following problem list: hypotension, pain, infection, hyperglycaemia

A
  1. Hypotension
  2. Pain
  3. Infection
  4. Hyperglycaemia
217
Q

How does hyperglycaemia make the prev problems worse?

A

Dehydration and poor wound healing

218
Q

What should you write instead of normal saline?

A

0.9% sodium chloride

Resus - 500mL, IV, over 30m

Mainten - 1L, IV, over 8hrs

219
Q

List examples of the drugs along the analgesic ladder

A
  1. Mild - paracetamol and NSAIDs
  2. Mod - codeine, co-codamol, dihydrocodeine, co-dydramol, tramadol, tramacet, BuTrans
  3. Sev - oramorph, MST, oxycodone, fentanyl
220
Q

What should you document for the pulse?

A

Both the rate and the rhythm

221
Q

What do you assume if the ulcer probes to bone?

A

Osteomyelitis

222
Q

What could cause low BP?

A

Poor oral intake, osmotic diuresis, sepsis

223
Q

When would HbA1c not be valid?

A

Haemoglobinopathies, rapid red cell turnover, sig renal failure

224
Q

At what eGFR should you avoid using NSAIDs and metformin?

A

<30mL/min

225
Q

What should you check if a T2DM comes through casualty on metformin?

A

How unwell they are, any evidence of pulm oedema, eGFR

226
Q

When should you stop the sliding scale/VRII?

A

When the pt is eating/drinking to avoid the hrly finger prick testing

227
Q

Which heparin do you give if the eGFR <30mL/min?

A

Switch to s/c unfractionated 5000U BD

228
Q

What do you give for VTE prophylaxis?

A

LMWH s/c enoxaparin 40mg OD + TED stockings

229
Q

Which drugs are having an AKI a red flag for?

A

Ramipril, Metformin, LMWH

230
Q

What is the hallmark of insulin def?

A

Ketones

231
Q

What is the quantitive value of abnormal and significant blood ketones?

A

> 0.6 Abnormal

>1.5 Significant

232
Q

What is C-peptide a marker of?

A

Endogenous insulin production

233
Q

What is hypoglycaemia defined as?

A

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
Q

What’s important to know before treating a pt’s hypoglycaemia?

A

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
Q

When would you not use IM glucagon?

A

Malnutrition + Chronic Liver Disease

236
Q

What can predispose to a high BM in hospital?

A

Sepsis
Immobility
Food Choices
Incorrect Insulin

237
Q

Workup for High BM

A

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
Q

Pain: Nociceptive vs Neuropathic

A

Nociceptive: somatic or visceral a/w tissue injury

Neuropathic: PNS or CNS a/w nerve injury

239
Q

What are other causes of pain in cancer pts aside from the cancer itself?

A

Anticancer tx (mucositis), related debility (constipation), concurrent disorder (OA)

240
Q

What are examples of weak and strong opiates?

A

Weak: codeine, tramadol, buprenorphine

Strong: morphine, oxycodone, diamorphine, alfentanil, fentanyl

241
Q

What are the different doses of co-codamol?

A

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
Q

What are the different morphine preparations?

A

Immediate release: liquid oramorph (10mg/5mls or 20mg/1ml) and sevredol tabs (10, 20, 50mg)

Sustained release: MST 12hrly and MXL 24hrly

243
Q

What are the exceptions to the general rule of not mixing opioids?

A

You can give prn oxycodone for break through w diamorphine, alfentanil, fentanyl

244
Q

What should the pt be counselled on regarding opioid use and driving?

A

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
Q

What is the total body fluid of a 70kg adult?

A

42L

246
Q

How is total body fluid split up?

A

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
Q

Which membranes separate IC vs EC and interstitial vs intravascular?

A

Cell + Capillary

248
Q

How do the cell membranes affect how the equilibrium is kept?

A

Cell: active and passive processes

Capillary: hydrostatic and oncotic pressures

249
Q

What are the daily requirements of fluids + electrolytes according to NICE?

A

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
Q

What are the two main types of IV fluids?

A

Crystalloids: 0.9% Sodium Chloride, Hartmann’s, Dextrose

Colloids: Albumin + Gelofusine

251
Q

What are the 5R’s of giving fluid?

A 
Resus
Replace
Routine
Redistribution
Reassessment
252
Q

Which bag of fluid can you add potassium to?

A

0.9% Sodium Chloride: usually comes premixed and can give more per litre in ICU

253
Q

What is the problem w prescribing too much 0.9% NaCl?

A

Hyperchloraemic Met Acidosis: inc Cl and dec HCO3

254
Q

How would you assess fluid balance?

A

Overload: raised JVP, pulm oedema, sacral/peripheral oedema

Deplete: dry mucous membranes, red skin turgor, sunken eyes, inc CRT, tachycardic, hypotensive

255
Q

What are insensible losses?

A

Inc daily requirements: if the pt is septic ie febrile and tachycardic, on NIV/tachypnoeic, inc bowel output eg stoma/diarrhoea, burns victim

256
Q

What imbalances does D+V create?

A

D: low K and acidosis

V: low KCl and alkalosis

257
Q

What is the composition of the crystalloids?

A

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
Q

What is the bicarbonate in Hartmann’s present as in the bag?

A

Lactate -[Liver]-> Bicarbonate

Therefore if the pt is septic it’ll make serial lactate measurements difficult to interpret

259
Q

Which fluid should NOT be used for resus?

A

Dextrose: it’s hypotonic so will be rapidly taken up into cells

260
Q

What is the classic maintenance fluid regime?

A

One Salty + Two Sweet: 0.5/1L Sodium Chloride w 40mmol KCl + 1L 5% Dextrose

261
Q

What is the max rate of potassium on a non monitored ward?

A

10mmol/hr

262
Q

What is the max rate of an electric fluids pump?

A

1500ml/hr = 500ml/20mins

263
Q

Who should you AVOID giving Hartmann’s to?

A

Pts who are/at risk of hyperK

264
Q

What is the Holliday-Segar formula for calculating maintenance fluids in children?

A

100ml/kg/day for first 10kg

50ml/kg/day for second 10kg

20ml/kg/day for every kg after

265
Q

What is the fluid requirement for a child in DKA?

A

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
Q

What is an earlier sign than a drop in BP for dehydration?

A

Tachycardia

267
Q

Why is your serum potassium a poor reflection of total body potassium?

A

The vast majority is in the cells

268
Q

What is the fail safe first bag of maintenance?

A

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
Q

When would you put more potassium in fluids?

A

If the pt is deficient or on fixed rate insulin

270
Q

Def of High Output Stoma

A

> 1L/day x3 or >2L/day x2

271
Q

What are the causes and effects of a high output stoma?

A

It’s a new stoma, short bowel syndrome, sepsis, incomplete obstruction, prokinetics

272
Q

What are the effects of a high output stoma?

A

Dehydration and AKI, low Na/Mg/B12, wt loss

273
Q

Mx of High Output Stoma

A

Resus, check and replace electrolytes, strict fluid balance, tx underlying cause, dietitian review

  1. Dietary Measures
  2. Loperamide/Omeprazole
  3. Dbl Strength Dioralyte/Lansoprazole
  4. Codeine
274
Q

What are the different MOA for contraception?

A

COCP - inhibits ovulation POP - thickens cervical mucus Depot/Implant - both of above IUS - prevents endometrial proliferation IUD - dec sperm motility and survival

275
Q

What are the UKMEC4 for the CHC?

A

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
Q

What cancers are at inc/dec risk w the COCP?

A

Inc: breast + cervical Dec: ovarian, endometrial, colorectal

277
Q

When should the mirena be inserted?

A

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
Q

What should you advise before the removal or the mirena?

A

Use barrier methods/avoid intercourse for 7d prior to removal

279
Q

When should a woman w the mirena seek medical advice?

A

If menstrual abnormalities persist beyond 6m, any lower abdo pain fever discharge, believes she is preg

280
Q

What are the types of long acting contraception?

A

Reversible: depot, implant, IUS/IUD Non-Reversible: sterilisation

281
Q

What are the four UKMEC categories?

A

1: No Restriction 2: Adv > Dis 3: Dis > Adv 4: Absolute CI

282
Q

What is the PEARL index?

A

Risk of pregnancy per 100 women yrs ie no of women out of 100 who would fall preg per year

283
Q

What are the different methods of emerg contraception?

A

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
Q

What are the risks of the copper IUD?

A

Expulsion: 1/20 Uterine Perforation: 2/1000

285
Q

What is the most effective form of emerg contraception?

A

Copper IUD

286
Q

What is the most effective type of any contraception?

A

Implant

287
Q

What is the best LARC of choice for young pts?

A

Progesterone only implant as the IUS/IUD are UKMEC2 for women <20yrs

288
Q

When can the mirena and copper IUD start being relied upon?

A

Mirena: after seven days Copper IUD: immediately

289
Q

Which types of contraception are unaffected by AEDs?

A

Depot, Mirena, Copper IUD

290
Q

What should you do if you miss one COCP?

A

Take the last pill even if it means taking two pills in one day and then continue as normal

291
Q

What should you do if you miss two COCP?

A

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
Q

What should you do if the change of COCP patch is delayed at the end of wk1 or wk 2 by >48hrs?

A

Start barrier method for 7d and consider emerg if UPSI was in the last 5d

293
Q

What should you do if the removal of COCP patch is delayed at the end of wk3?

A

Remove asap and then use the next patch on the usual start day even if withdrawal bleeding is still occurring

294
Q

What is the LAM?

A
  1. Postpartum <6m 2. Fully Breastfed 3. Amenorrheic
295
Q

When do women require contraception after birth who do not meet LAM criteria?

A

Day 21: if starting COCP use condoms for 7d vs POP use condoms for 2d

296
Q

When can an IUS/IUD be inserted following childbirth?

A

Within 48hrs or after 4wks

297
Q

When should pts who have taken the emerg pill come back?

A

If they vomited <2hrs to repeat the dose

298
Q

How does the pts BMI/wt impact the choice of morning after pill?

A

If BMI>26 or wt>70 give double dose LNG or UPA

299
Q

What are the progestogen SEs?

A

Nausea Headache Breast Pain

300
Q

What are The Fraser Guidelines?

A

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
Q

What red the efficacy of the COCP?

A

Vomiting within 2hrs of taking a pill + medications that induce diarrhoea/enzyme inducers

302
Q

What are the estradiol SEs?

A

GI Discomfort + Wt Changes

303
Q

How long does it take the POP to have an affect?

A

If first five days of cycle immediate otherwise 2d

304
Q

What should you do if you miss one POP?

A

If <3h continue as normal vs >3h (or 12h if cerazette) take asap and use barrier method for 2d

305
Q

When can/do you stop contraception?

A

Women <50: stop >=2yrs amenorrhoea + continue COCP/depo until 50 Women >50: stop >=1yr amenorrhoea + switch COCP/depo to POP/non-hormonal

306
Q

Which form of combined contraception does NOT inc your risk of clots?

A

Transdermal Patch

307
Q

How long may it take fertility to return after the depo?

A

6-12m

308
Q

When is laparoscopic sterilisation affective?

A

From the first period

Year 6 - PSA (4 decks)

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