PSA - mock questions Flashcards
77 year old man with acute SOB and bilateral pitting oedema. SpO2 94% on 40% oxygen
a) Likely diagnosis
b) Management - drug, dose and route
c) What is a good marker of the effectiveness of furosemide after a few days of treatment?
a) Pulmonary oedema secondary to CCF
b) - Furosemide 40 mg IV (10 mg/ml)
- IV GTN
c) Weight loss - objective marker of fluid offloading
- other indicators will be clinical response (i.e. ankle swelling, bibasal creps, oxygen requirement, breathlessness and RR, etc.)
54 year old male, 12 hours post-THR. Needs anticoagulation. No major PMHx, normal eGFR
a) Give drug, with route and dose
a) Tinzaparin sodium*, 4500 units, SC
* Note: tinzaparin is easier to find dose for in BNF than dalteparin
Diabetic presents with confusion and sweaty. BM = 1.9. You have IV access. HR 106, other obs normal.
a) Give IV fluid
b) If no access and unconscious, what would you give?
c) If could take oral, what would you give?
a) 50 - 100ml 20% glucose (will deliver 10 - 20g glucose)
- if unavailable, give 150 - 200ml of 10% glucose
b) IM glucagon - 1g dose for adults
- If no response after 10 mins - give IV glucose
c) 10 - 20g glucose by mouth
Patient on tacrolimus following renal transplantation.
a) What MUST you clarify?
a) The brand name (dose may differ slightly between brands of transplant rejection drugs, so must be prescribed by brand)
Patient with AKI, develops confusion. Why is this common in patients on certain medications?
- Renal failure - drugs that are renally excreted will accumulate
- Higher concentration of certain drugs (eg. opioids, sedatives, anticholinergics, steroids, antihypertensives, etc.) may lead to confusion
62 year old woman with metastatic breast Ca and back pain. On 72h fentanyl patch (50 micrograms/hr), but requiring analgesia for breakthrough pain
a) Calculate her breakthrough pain dose of morphine
b) As well as morphine, what could be used to manage her breakthrough pain acutely
c) Why is oxycodone safer than morphine in renal failure?
a) 1/6th (or 1/10th) of total daily opioid dose
… fentanyl 50 micrograms/hr = 120 mg PO morphine daily
… breakthrough dose = 120/6 = 20 mg morphine PO
b) Fentanyl:
- buccal
- sublingual
- intranasal*
*Note: this has a very quick onset, so works well for sudden acute pain that may be caused by spinal nerve compression
c) - Oxycodone is metabolised into inactive metabolites by the liver
- Therefore, provided liver function is adequate there will be less accumulation of toxic or potent metabolites than with morphine in the context of renal failure
73 year old male with dysuria and frequency. Has penicillin allergy. eGFR 40. E.coli grown on MSU.
a) What antibiotics would be first line? (dose, duration)
b) What antibiotics would NOT be suitable?
a) - Trimethoprim 200 mg PO twice-daily, 7-day course (3-day course in females)
b) - Amoxicillin or pevmicillinam (due to pen allergy)
- Nitrofurantoin (as eGFR < 45)*
*Where potential benefit outweighs risk, may be used for 3- 7 days if eGFR 30 - 44 (however, trimethoprim would be first line)
Patient undergoing elective surgery tomorrow.
Warfarin stopped a week prior, but INR still > 1.5 (1.6).
a) What should you do?
a) Give Vitamin K (phytomenadione) 1 - 5 mg PO
- To be given the day before elective surgery to reverse any ongoing anticoagulant effect of stopped warfarin
Patient started on rivaroxaban.
a) What should you tell him about adminstration?
a) Take with food
- aids absorption for full efficacy
Patient on oral contraceptive. Starting topiramate for migraine prophylaxis.
a) What is the possible interaction here?
b) Advice for patient
a) Topiramate is an enzyme inducer
- Leads to increased metabolism of contraceptive
- Leading to reduced efficacy - risk of pregnancy
b) - Switch to another contraceptive, unaffected by the drug (eg. condoms, copper coil)
- This should be for as long as patient is on enzyme inducer and for 4 weeks after treatment is finished
Co-amoxiclav.
a) Possible effect on LFTs and liver
b) Other common adverse effects
a) Cholestatic jaundice:
- Raised bilirubin, mildly raised ALT and more markedly raised Alk Phos
b) C. diff
SSRIs.
a) What one thing should patients be warned about?
b) Other possible adverse effects
a) - SUICIDE ideation in first few weeks
b) - Interactions (more with citalopram)
- Gastrointestinal bleeding (when combined with NSAIDs, antiplatelets, or certain other drugs)
- Electrolyte abnormalities - hyponatraemia, hypokalaemia
- QT prolongation (more with citalopram)
- Serotonin syndrome (especially in combination with certain other drugs - antidepressants, opioids, etc.)
ACE inhibitors.
a) What rise in creatinine is acceptable?
a) < 20 %
- more than this may require investigation and changing of antihypertensive
45 year old woman admitted with acute exacerbation of asthma. Her average pre-breakfast BM is 6.1. Her average pre-evening meal BM is 18.0.
- PMHx: asthma, T1DM
- Repeat prescriptions: Humulin M3 20 Units BD, Clenil inhaler, salbutamol inhaler
- Acute meds: amoxicillin 1 g IV 8-hourly, prednisolone 40 mg OD for 7 days
a) What should be done with her insulin?
b) What may have caused the rise in her evening BMs?
a) Increase Humulin M3 dose to 22 Units
- 10% increases are generally acceptable in this instance
b) Prednisolone
Patient with hypothyroidism on 50 micrograms of levothyroxine. Latest TFTs are:
- TSH: 11.0 (0.4 - 4.5), free T4: 5.0 (10 - 21)
a) Management plan?
b) Directions for administration
a) Increase the thyroxine dose:
- start at 50 micrograms (25 in the elderly)
- generally increase in 25 - 50 microgram increments every 3 - 4 weeks
- so in this case increase to 75 or 100 micrograms
- review TFTs every 6 - 8 weeks until euthyroid
- usual maintenance dose: 100 - 200 micrograms
b) Take at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication (especially known interacting drugs)
