PSA Revision

Question 1

Effect of a P450 inducer?

Answer 1

Increase metabolism of P450, therefore drug exerts less of an effect

Question 2

Effect of a P450 inhibitor?

Answer 2

Reduced metabolism of P450, therefore drug exerts more of an effect.

Question 3

Examples of P450 Inducers ?

Answer 3

Increased enzyme activity, decreased drug concentration

• PC BRAS
• Phenytoin
• Carbamazepine
• Barbiturates
• Rifampicin
• Alcohol (chronic excess)
• Sulphonylureas

Question 4

Examples of P450 inhibitors?

Answer 4

AODEVICES

• Allopurinol
• Omeprazole
• Disulfiram
• Erythromycin
• Valproate
• Isoniazid
• Ciprofloxacin
• Ethanol (acute intoxication)
• Sulphonamides

Question 5

Drugs to stop before surgery - COCP?

Answer 5

4 weeks before surgery

Question 6

Drugs to stop before surgery

- Lithium

Answer 6

Day before

Question 7

Drugs to stop before surgery

- Potassium sparing diuretics and ACEi?

Answer 7

Day of surgery

Question 8

Drugs to stop before surgery

• Warfarin/heparin)
• Antiplatelets

Answer 8

• Variable.

Generally Warfarin is stopped and bridged with LMWH.

Question 9

Drugs to stop before surgery -

Oral hypoglycaemic drugs and insulin?

Answer 9

Patient is NBM before surgery.

Metformin should be stopped because it will cause lactic acidosis.

In all cases - a sliding scale should be started instead - hourly blood glucose monitoring and adjust hourly dose.

Question 10

Mnemonic for drugs to stop before surgery?

Answer 10

I LACK OP

• Insulin
• Lithium
• Anticoagulants
• COCP/HRT
• K-sparing diuretics
• Oral hydoglycaemics
• Perindopril

Question 11

Management of long-term corticosteroids (pred) before surgery?

Answer 11

Increase steroid requirement

At IOA, patient should be given IV steroids.

Question 12

Drugs to stop for a patient with haemoptysis?

Answer 12

Aspirin (Antiplatelet)

Enoxaparin (LMWH)

Question 13

Drugs to stop patient is hyperkalaemic?

Answer 13

ACEi
IV fluid with K should be stopped.

Also patient is receiving 6g of paracetamol so should be stopped.

Question 14

Common pitfalls for prescribing?

Answer 14

Ensuring we have correct patient’s prescription/drug chart

Noticing and recording allergies

SIgning the front of the chart.

Considering contraindications for each drug we prescribe.

Consider the route for each drug we prescribe

Consider the need for IV fluids.

Consider need for thromboprophylaxis

Consider need for antiemetics

Consider need for pain relief.

Question 15

What is the PReSCRIBER mnemonic?

Answer 15

Patient Details 
Reaction 
Sign the front of the chart 
check for Contraindications to each drug
Prescribe Intravenous fluids if needed 
Prescribe Blood clot prophylaxis if needed
Prescribe antiEmetic if needed
Prescribe pain Relief if needed.

Question 16

When working on a new chart what must you write?

Answer 16

3 piece of patient identifying information on the front

• Patient Name
• DOB
• Hospital Number

Question 17

Reactions for drug charts?

Answer 17

Check allergy box to include any drug reaction

Don’t forget that co-amoxiclav and Tazocin both contain penicillin.

Question 18

Contraindications in drug charts? - Bleeding

Answer 18

Consider whether it is contraindicated.

Drugs that increase bleeding (aspirin, heparin and warfarin). Should not be given to those risk of bleeding (liver disease).

Prophylactic heparin is contraindicated in acute stroke - risk of bleeding.

Be wary that enzyme inhibitors AODEVICES can increase PT and INR.

Question 19

Contraindications for drug chart - Steroids?

Answer 19

Side effects -

• Stomach ulcers
• thin skin
• Oedema
• Right + left heart failure
• Osteoporosis
• Infection
• Diabetes
• Cushing’s syndrome

Question 20

Contraindications for rugs - NSAIDS?

Answer 20

• NSAID
• No urine (renal failure_
• Systolic dysfunction (heart failure)
• Asthma
• Indigestion
• Dyscrasia (clotting abnormality)

Aspirin, whilst not technically an NSAID. It is not contraindicated in renal or heart failure.

Question 21

Antihypertensives - SE?

Answer 21

Hypotension that may result from all groups of antihypertensives.

Bradycardia = beta blockers + CCBs .

Electrolyte disturbances with ACE and diuretics.

Individual drug classes have specific side effects
- ACEi = Dry cough
- Beta-blockers = wheeze in asthmatics
- CCB = Peripheral oedema and flushing
- Diuretics = renal failure. Loop diuretics can also cause gout.
Spironolactone causes

Question 22

Route for patients?

Answer 22

if vomiting = antiemetics should be given by non-oral routes = IV/IM/SC

E.g Cycline 50mg 8hrly IV or PO
Metoclopramide 10mg 8 hrly.

If a patient is nil by mouth should still receive oral medication.

Question 23

When are IV fluids prescribed?

Answer 23

As replacement for dehydrated/acutely unwell patient

As maintenance in patient who is nil by mouth.

Question 24

Which fluid to prescribe?

Answer 24

0. 9% saline UNLESS:
   - Patient is hypernatraemic or hypoglycaemic: then give 5% dextrose instead.
   - Has ascites: give human-albumin solution instead.
   - Shocked with systolic BP <90: give gelofusine instead as it has high osmotic content so stays IV, thus stays intravascularly, maintaining BP for longer.
   - Is shocked from bleeding: give blood transfusion, but a colloid first if no blood available.

Question 25

How much fluid and how fast? - tachycardic or hypotensive

Answer 25

If tachycardic or hypotensive give 500ml Immediately in 10 mins 250ml if heart failure. Then reassess patient, especially HR BP and urine output to assess response + speed of next bag.

Question 26

How much fluid and how fast - oliguric (not due to obstruction)?

Answer 26

IL over 2-4hrs. Then reassess HR, BP and urine output.

Question 27

How volume depleted is a patient with reduced urine output (<30ml/h)

Answer 27

500ml of fluid depletion

Question 28

How volume depleted is a patient with reduced urine output (<30ml/h) plus tachycardia?

Answer 28

1L of fluid depletion

Question 29

How volume depleted is a patient with reduced urine output (<30ml/h), tachycardic plus is shocked?

Answer 29

Indicated >2L of fluid depletion.

Question 30

Maintenance fluids requirements over 1 day?

Answer 30

``` Adults = 3 IV fluid per 24hrs Elderly = 2L per 24hrs ``` Adequate electrolytes are provided by 1L of 0.9% saline and 2L of 5% dextrose. 1 salty and 2 sweet. K+ = Bags of 5% dextrose or 0.9 saline containing KCL can be used. Patients require roughly 40mmol KCL per day = 20mmol KCL in 2 bags. Never give IV potassium at more than 10mmol/hour.

Question 31

How fast to give maintenance fluids?

Answer 31

If 3 L = 8hrly bags If 2 L = 12hrs bags. In real life - check patients' U+E, confirm what to give. Check patient is not fluid overloaded (increased JVP, peripheral and pulmonary oedema. Ensure patient's bladder is not palpable.

Question 32

Blood clot prophylaxis?

Answer 32

Prophylactic LMWH - dalteparin 5000 units daily s/c. Compression stocking to prevent VTE. If a patient is bleeding or at risk of bleeding (recent CVA) - they should not be prescribed warfarin or heparin. Patients with PAD should not be prescribed compression stockings.

Question 33

Antiemetics for patients that are nauseated?

Answer 33

Regular antiemetics - Cyclizine 50mg 8hrly IM/IV/ oral. Most cause fluid retention. - Metoclopramide 10mg 8hrly IM/IV.

Question 34

Antiemetics for non-nauseated patients?

Answer 34

PRN antiemetics - cyclizine 50mg IV/IM/oral. - Metoclopramide 10mg up to 8hr IM/IV. Cyclizine (anti-histamine) for most patients except cardiac cases when its safer to give metoclopramide.

Question 35

When to avoid metoclopramide?

Answer 35

Crosses the BBB Patients with Parkinson's diseases due to risk of exacerbating symptoms young women due to risk of dyskinesia - unwanted movement especially acute dystonia.

Question 36

Pain relief for patients?

Answer 36

No pain = PRN paracetamol 1g 6hrly. Mild pain = Paracetamol 1g 6 hourly oral regularly. Codeine 30mg up to 6hourly oral. Severe pain = Co-codamol 30.500, 2 tablets 6-hourly oral. Morphine sulphate: 10mg up to 6 hourly oral. Morphine in order of effectiveness - Morphine sulphate (oramorph) - Subcutaneously - intravenously. Ensure only 4g of paracetamol is being prescribed.

Question 37

Management of neuropathic pain?

Answer 37

Nerve damage usually shooting, stabbing or burning. First line = Amitriptyline (10mg oral nightly) or pregabalin (75mg oral 12-hourly). Duloxetine (60mg oral daily) indicated in painful diabetic neuropathy.

Question 38

Bendroflumethiazide and potassium?

Answer 38

Leads to hypokalaemia by increasing potassium excretion. Remember that ACEi can lead to increased Potassium.

Question 39

Lisinopril and potassium?

Answer 39

Causes kyperkalaemia through reduced aldosterone production and thus reduced potassium excretion in the kidneys. Loop and thiazide = hypokalaemia. Aldosterone antagonist and ACEi cause hyperkalaemia.

Question 40

NSAIDS and indigestion?

Answer 40

Inhibits prostaglandin synthesis therefore risk of influencing inflammation and ulceration. Oral steroids inhibit epithelial renewal thus predispose to ulceration.

Question 41

NSAIDS and renal failure?

Answer 41

NSAIDS reduce renal artery diameter and thereby reduce kidney perfusion and function. ACEi - reduce ACEi and stop aldosterone.

Question 42

Ibuprofen and asthma?

Answer 42

Must stop as contraindicated!

Question 43

Trimethoprim and methotrexate?

Answer 43

Avoid as risk for bone marrow toxicity. Therefore stop the trimethoprim.

Question 44

Methotrexate and sepsis?

Answer 44

Must exclude neutropenic sepsis.

Question 45

Furosemide and sodium?

Answer 45

Hyponatraemia and Hypokalaemia.

Question 46

Amlodipine side effect?

Answer 46

Peripheral oedema. incorrectly treated with furosemide therefore stop amlodipine.

Question 47

When patient has a high INR what should you stop?

Answer 47

Both warfarin and heparin.

Question 48

Verapamil and beta blockers?

Answer 48

Risk of bradycardia and hypotension. Make sense to stop the verapamil causing the peripheral oedema.

Question 49

Beta blockers and asthmatics?

Answer 49

Contraindicated due to bronchospasm. NSAIDS used with caution.

Question 50

Normal cardioprotective and treatment dose of aspirin?

Answer 50

75 mg daily Stroke dose = 300mg daily.

Question 51

Microgynon?

Answer 51

CI in patients with migraine. Increases risk of stroke too.

Question 52

Prophylactic heparin in stroke?

Answer 52

CI following stroke.

Question 53

Novomix is given incorrectly

Answer 53

Never given IV All insulin is given IV except for sliding scales.

Question 54

Clozapine worrying side effect?

Answer 54

Antipsychotic. - Agranulocytosis resulting in neutropenia.

Question 55

Causes of a microcytic anaemia?

Answer 55

IDA Thalassaemia Sideroblastic anaemia

Question 56

Causes of normocytic anaemia ?

Answer 56

Anaemia of Chronic Disease Acute blood loss Haemolytic anaemia Renal failure (chronic)

Question 57

Macrocytic anaemia cause?

Answer 57

- B12/folate deficiency - Excess alcohol - Liver disease (non-alcohol) - Hypothyroidism - Haematological disease beginning with M: myeloproliferative, myelodysplasia, multiple myeloma.

Question 58

Hypovolaemic Hyponatraemia causes?

Answer 58

Fluid loss (especially diarrhoea/vomiting) Diuretics Addison's disease

Question 59

Euvolaemic hyponatraemia causes?

Answer 59

SIADH Psychogenic polydipsia Hypothyroidism SIADH = Small cell lung cancer, Infection, Abscess, Drugs (carbamazepine, antipsychotics) and Head injury.

Question 60

Hypervolaemic hyponatraemia causes?

Answer 60

``` Heart failure Renal failure Liver failure Nutritional failure Thyroid failure ```

Question 61

Causes of hypokalaemia?

Answer 61

DIRE - Drugs (loop and thiazide) - Inadequate intake or intestinal loss - Renal tubular acidosis - Endocrine (Cushing's and Conn's syndrome) - excess aldosterone

Question 62

Causes of hyperkalaemia?

Answer 62

DREAD ``` Drugs, Spironolactone, ACEi Renal failure Endocrine: Addisons Artefact (due to clotted sample) DKA (insulin to treat DKA potassium drops requiring regularly hourly monitoring.) ```

Question 63

Causes of hypernatraemia?

Answer 63

All begin with D - Dehydration - Drips (IV saline) - Drugs (effervescent tablet preps or IV prep with a high sodium content). - Diabetes insipidus (effectively the opposite of SIADH)

Question 64

Causes of high neutrophils (neutrophilia)

Answer 64

Bacterial infection Tissue damage Steroids

Question 65

Causes of low neutrophils?

Answer 65

Viral infection Chemo and radiotherapy Clozapine Carbimazole (antithyroid)

Question 66

Causes of high lymphocytes (lymphocytosis)?

Answer 66

Viral infection Lymphoma Chronic Lymphocytic Leukaemia

Question 67

Causes of low platelets? Thrombocytopenia

Answer 67

Reduced production - Infection (viral) - Drugs (penicillamine (rheumatoid) - Myelodysplasia, myelofibrosis, myeloma. Increased destruction - Heparin - Hypersplenism - DIC - ITP - HUS/TTP

Question 68

Causes of high platelets?

Answer 68

Reactive - Bleeding - Tissue damage - INflammation, malignancy - Post-splenectomy Primary - Myeloproliferative disorder)

Question 69

Causes of a raised Urea?

Answer 69

Could indicate AKI Upper GI bleed. Therefore a patient with a raised urea and normal creatinine who is not dehydrated (look at haemoglobin for a GI bleed).

Question 70

Causes of an pre-renal AKI?

Answer 70

Prerenal - Urea rise >> creatine rise. eg urea 19 and creatinine 110. Dehydration Sepsis /Blood loss Renal artery stenosis Multiple urea by 10. If it exceeds creatinine then this suggests prerenal aetiology.

Question 71

Causes of a renal AKI?

Answer 71

Urea rise << creatinine rise, bladder or hydronephrosis not palpable. Due to ischaemia - due to prerenal AKI, causing acute tubular necrosis) Nephrotoxic antibiotics - Gentamicin, vancomycin, tetracyclines. Tablets (ACEi, NSAIDs) Radiological contrast Injury Negatively birefringement crystals (gout) Syndromes (glomerulonephridites) Inflammation (Vasculitis) Cholesterol emboli

Question 72

Causes of a postrenal AKI?

Answer 72

Urea rise << creatinine rise, bladder or hydronephrosis may be palpable depending on level of obstruction. In lumen: stone or slough papilla. In wall: Tumour, fibrosis, External pressure: Benign prostatic hyperplasia, prostate cancer, lymphadenopathy, aneurysm.

Question 73

Causes of a raised Alk Phos

Answer 73

``` Any fracture Liver damage K(Cancer) Paget's Pregnancy Hyperparathyroidism Osteomalacia Surgery ```

Question 74

Pattern of prehepatic jaundice and cause?

Answer 74

Raised isolated Bilirubin Cause: Haemolysis, Gilbert's and Crigler-Najjar Syndrome

Question 75

Pattern of intrahepatic and cause of jaundice?

Answer 75

Raised AST/ALT and raised bilirubin ``` Cause: Fatty liver Hepatitis & Cirrhosis (due to 1) alcohol 2) Viruses (Hep A-E, CMV, EBV) 3) drugs (paracetamol, statins, rifampicin) ``` Malignancy Metabolic: Wilson's disease/haemochromatosis Heart failure

Question 76

Pattern of post-hepatic jaundice and causes?

Answer 76

Bilirubin increased ALP increased In lumen: Stone (gallstone), drugs causing cholestasis (Flucloxacillin, co-amoxiclav, nitrofurantoin, steroids, sulphonylurea) In wall: tumour (cholangiocarcinoma), PBC, PSC. Extrinsic pressure: pancreatic or gastric cancer, lymph node.

Question 77

TFTS?

Answer 77

Might be asked to change levothyroxine dose according to TFTs results for patient with hypothyroidism. Use TSH as a guide. Target range ~0.5-5mlU/L. If TSH range <0.5 - Decrease dose as it is being suppressed. If TSH 0.5-5 = Nil action - same dose If >5 = Increased dose. increased by smallest increment offered.

Question 78

Interpretation of Chest X-ray?

Answer 78

PRIM Projection (PA/AP). Rotation - Distance between spinous process and clavicles. Inspiration - 7th anterior rib transects diaphragm. Markings Structure - Heart should be less than 50% of width of lungs. - Look for effusion, pneumonia, oedema. - Trachea should be central and if not consider collapse (towards) or pneumothorax (away).

Question 79

Interpretation of arterial blood gases?

Answer 79

Subtract 10 from the FiO2 and if the PaO2 exceeds this calculated number then the patient is not hypoxic.

Question 80

Presence of respiratory failure

Answer 80

``` Type 1 (most common) - Low or normal PaCO2 (fast/normal breathing) and can be caused by anything that damages the heart or lungs causing SOB. ``` ``` Type 2 - Less common - High PaCO2 (slow shallow breathing) - Low oxygen. Blue bloaters of COPD - less commonly neuromuscular failure or restrictive chest wall abnormalities. ```

Question 81

How to check ABG?

Answer 81

Look at pH. Then look at PaCo2 to indicated respiratory cause. If only HCo2 is abnormal this is a metabolic cause. If both increased or both decreased this indicates compensation. If pH normal fully compensated. If abnormal partially compensated. If both PaCO2 and HCO3 are abnormal but in opposite directions then there is coexistent metabolic and respiratory disease.

Question 82

ECG rate?

Answer 82

Rate: Divide 300 by number of large squares between each QRS. Normal 60-100 bpm. <60bpm. Rhythm - P waves. Is it in sinus rhythm Think about first, second or third degree HB. QRS - complex. Normally <3 small squares. If >3 then BB is present. Height for LVH. ST segment - if elevated then: Infarct or pericarditis - If depressed then ischaemic or digoxin. T waves - Height :if more than 2.s QRS then Hyperkalaemia likely. - INversion: normal in aVR and I leads. In other leads suggests old infarction/LVH.

Question 83

Common drugs that require monitoring?

Answer 83

``` Digoxin Theophylline Lithium Phenytoin Vancomycin ```

Question 84

When adjusting these drugs?

Answer 84

Move up in the smallest possible increment. this is when response is inadequate and low serum drug level. If adequate response to drug - normal or low serum drug level then no change required. If adequate response to drug and high serum drug level then decrease the dose. If there is evidence of toxicity then omit the drug. (only exception is gentamicin where a high serum level without signs of toxicity) should pre-empt a decrease in frequency by 12hr rather than reducing the dose e.g changing from every 24hrs to every 36hrs.

Question 85

Signs of digoxin toxicity?

Answer 85

Digoxin = Confusion, nausea, visual halos and arrhythmias

Question 86

Lithium toxicity?

Answer 86

Early: tremor Intermediate: tiredness Late: arrhythmias, seizure, coma, renal failure and diabetes insipidus

Question 87

Phenytoin toxicity?

Answer 87

``` Gum hypertrophy Ataxia Nystagmus Peripheral neuropathy Teratogenicity ```

Question 88

Gentamicin toxicity?

Answer 88

Ototoxicity and nephrotoxicity

Question 89

Vancomycin toxicity?

Answer 89

Ototoxicity and nephrotoxicity

Question 90

What to do generally if there is evidence of toxicity?

Answer 90

``` Stop drug (± find alternative) Supportive measures (IV fluid) Give antidote ```

Question 91

Gentamicin monitoring?

Answer 91

Aminoglycoside for severe infections. Doses calculated according to patients weight and renal function. High dose regimen of 5-7 mg/kg once daily. Patients with severe rena lfailure or endocarditis receive divided daily dose of 1mg/kg 12hrly (renal failure) or 8hrs in endocarditis. Important because of gentamicin can cause ototoxicity and nephrotoxicity

Question 92

Regimen monitoring for gentamicin?

Answer 92

Measure gentamicin levels are particularly times such as 6-14hr after last gentamicin infusion is started. Use a nomogram. f the resultant point on the graph falls within the 24 h area (q24h) then continue at the same dose; if it falls above the q24h area then change the dosing interval as follows: - if point falls in the q36h area change to 36-hourly dosing - if point falls in the q48h area change to 48-hourly dosing - if point rests above the q48h area repeat the gentamicin level and only re-dose when the concentration <1 mg/L.

Question 93

Management of a paracetamol overdose?

Answer 93

N-acetyl cysteine. IV fluids. Use the paracetamol nomogram. If the plasma paracetamol level is below the line the patient does not require NAC. If above they do. Paracetamol relies on glutathione therefore when this is used up, there is accumulation of NAPQI.

Question 94

Warfarin excess management?

Answer 94

Warfarin inhibits synthesis of Vit K dependent clotting factors (II, VII, IX, X). Prolongs the prothrombin time from which the INR is derived. Targets for INR in most patients is 2.5 unless there is recurrent thromboembolism while on warfarin or metal replacement where it becomes 3.5. if there is a major bleed causing hypotension or bleeding - Stop warfarin - Give 5-10mg IV vitamin K - Give prothrombin complex

Question 95

INR <6?

Answer 95

Reduce warfarin If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.

Question 96

INR 6-8?

Answer 96

Omit warfarin for 2 days then reduce dose If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.

Question 97

INR >8

Answer 97

Omit warfarin and give 1-5mg oral vitamin K. If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg. Vitamin K admin complicates the reintroduction of warfarin so only given when there is presence of bleeding or an INR exceeding 8.

Question 98

When deciding whether to stop ACEi and NSAIDs for high K and renal failure?

Answer 98

Stop both as they both can cause raised K. Can always restart again. Ibuprofen - decreases renal blood flow by inhibiting prostaglandins that normally dilate blood vessels flowing in the kidney.

Question 99

Neutropenic sepsis management alongside hyperkalaemia

Answer 99

Give PipTaz, Gentamicin, Paracetamol and Stop lisinopril.

Question 100

Hyponatraemia and confusion?

Answer 100

Stop patient's carbamazepine and furosemide, both contributing to the hyponatraemia.

Question 101

Trimethoprim in pregnancy?

Answer 101

Contraindicated in pregnancy - predisposed to neural tube defects. OCP during pregnancy is contraindicated!

Question 102

Digoxin and heart rate?

Answer 102

Bradycardia

Question 103

Addison's that are sick on steroids?

Answer 103

Increase for sick day rules.

Question 104

Asthma drugs contraindicated?

Answer 104

Bisoprolol Ibuprofen Withhold salbutamol inhalers when they are giving nebs.

Question 105

Management of acute heart failure?

Answer 105

Furosemide is the mainstay for acute heart failure and is administered IV.

Question 106

Atrial Fibrillation management in patient with asthma and peripheral oedema?

Answer 106

Can't use Beta-blocker Can't use Calcium Channel Blockers due to risk of peripheral oedema. (Amlodipine not really used, but diltiazem is used). Therefore digoxin.

Question 107

How are as required doses of morphine sulphate (oramorph) calculated?

Answer 107

one sixth of the total daily dose. - 1/6th of 30mg. Given up to every 4-6 hrs.

Question 108

Management of STEMI?

Answer 108

ABC + O2 (15L) with non-rebreather Hx/oe/inv. Diagnose STEMI Aspirin 300mg Morphine 5-10mg IV with metoclopramide 10mg IV GTN spray Primary PCI or thrombolysis B-blocker e.g atenolol 5mg oral (unless asthma/LVF). Transfer to CCU

Question 109

Management of NSTEMI?

Answer 109

ABC + O2 (15L) by non-breather mask. Hx/oe/ diagnose NSTEMI. Aspirin 300mg oral Morphine 5-10 mg IV with metoclopramide 10mg IV. GTN spray Clopidrogrel 300mg and LWM heparin 1mg/kg bd SC. Beta- blocker Transfer to CCU.

Question 110

Management of LVF

Answer 110

ABC + O2 (15L) by non-rebreather mask. Hx/oe/ diagnose NSTEMI. Aspirin 300mg oral Morphine 5-10 mg IV with metoclopramide 10mg IV. GTN spray Furosemide 40-80mg IV If inadequate response, isosorbide dinitrate infusion ± CPAP CCU

Question 111

Management algorithm for adult Tachycardia?

Answer 111

Assess using ABCDE approach Give oxygen + obtain IV Monitor ECG, BP, SpO2, record 12-lead ECG. Identify and treat reversible cause (electrolyte abnormalities). Adverse features? = Unstable - Shock, syncope, MI, HF. If unstable give DC shock up to 3 attempts. Then Amiodarone 300mg IV over 10-20mins and repeat shock followed by: Amiodarone 900mg over 24hr. If there are no adverse features and narrow QRS. - If the rhythm is irregular it is AF. = B-blocker or diltiazem or consider digoxin or amiodarone. If there narrow QRS and regular = vagal manoeuvres, adenosine 6mg rapid IV bolus, if unsuccessful give 12mg. If unsuccessful give another 12mg. Monitor ECG continuously. If sinus rhythm restored - re-entry paroxysmal SVT. - Record 12 lead ECG sinus rhythm - If recurs give adenosine again and consider choice of anti-arrhythmic prophylaxis. If Broad QRS with regular rhythm = VT = Amiodarone 300mg IV over 20-60 mins. Then 900mg over 24hr. If previously confirmed - SVT with BBB. Give adenosine as regular complex tachy. If irregular QRS - Seek expert help.

Question 112

Management of anaphylaxis?

Answer 112

``` ABC H/exam Remove the cause ASAP (blood transfusion) Adrenaline 500micrograms 1:1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV Asthma tx if wheeze. Amend drug chart allergies box. ```

Question 113

Management of acute exacerbation of asthma

Answer 113

``` ABC History of asthma 100% O2 by non-rebreather Salbutamol 5mg NEM Hydrocortisone 100mg IV or prednisolone 40-50mg oral (if moderate) Ipratropium micrograms neb) Theophylline (only if life threatening) ```

Question 114

Management of pulmonary embolism?

Answer 114

High flow oxygen Morphine LMWH If low BP - IV gelofusine --. Noradrenaline --> thrombolysis

Question 115

Managemet of GI bleed?

Answer 115

``` ABC History IV Cannulae Catheter (and strict fluid monitoring) Crystalloid Cross-match 6 units of blood Correct clotting abnormalities Camera Stop culprit drugs (NSAIDs, Aspirin, warfarin, heparin). ```

Question 116

Metabolic emergencies? - DKA

Answer 116

To diagnosis - Diabetic )- hyperglycaemia - BM often >30mmol/L - Keto (check urine and blood ketone) - Acidosis (low pH on ABG). IV fluid 1L stat then 1L over 1 hr, then 2hrs, then 4 hrs, then 8hrs. Sliding scale insulin. hunt for trigger (infection, MI, missed insulin) Monitor BM, K, pH.

Question 117

Metabolic HONK coma?

Answer 117

Hyperglycaemia (usually >35 mmol/L) HO (Hyperosmolar: osmolality over 340mmol/L (2x (Na +K) + urea + glucose) Manage same as DKA but half the rate of fluids.

Question 118

Hypoglycaemia?

Answer 118

BM blood glucose <3mmol/L. Give them a high-sugar snack. Otherwise give IV glucose via a cannula 100ml 20% glucose. If unable to eat and no cannula give IM glucagon 1mg.

Question 119

Acute poisoning?

Answer 119

ABC Cannula and catheter, strict fluid balance. Supportive measures Correct electrolyte disturbance Reduce absorption - gastric lavage, whole bowel irrigation (if lithium or iron) 3) charcoal. Increase elimination - Generous IV fluid + - N-acetyl cysteine (if paracetamol level at 4hrs or more is over the line on treatment nomogram). -Naloxone (if opiates have been taken and there is now slow breathing) - Flumazenil (if benzodiazepine have been taken).

Question 120

HTN management?

Answer 120

Treat BP >150/95 or >135/85 if any of the following are also present - Existing or high risk of vascular disease, stroke, peripheral vascular disease. - HTN organ damage. Target blood pressure on treatment - Patients aged less than 80 yrs aim for <140/85. and <135/85 for ambulatory or home measurements. If patient is over 80 add 10mmHg to systolic values. ``` Under 55 = A Over 55 or black = C A + C A + C + D A + C + D + diuretic, alpha blocker or b-blocker. ```

Question 121

IN the chronic setting of microalbuminuria due to diabetes what do you monitor and how do you treat it?

Answer 121

ACEi (ironically can worsen AKI but in the chronic setting offers cardiovascular + renal protection. Measure the albumin-creatinine ratio.

Question 122

Parkinson's management

Answer 122

Most commonly used regimen - co-beneldopa or co-careldopa If question presents a patient with very mild Parkinsons who is particularly concerned about finite period of benefit from levodopa - give a dopamine agonist (ropinirole) or MAOi (rasagiline).

Question 123

Epilepsy drug side effects | - Lamotrigine?

Answer 123

Rash - Rarely Steven Johnson syndrome.

Question 124

Epilepsy drug side effects? Carbamazapine?

Answer 124

``` Rash Dysarthria Ataxia Nystagmus Decreased sodium ```

Question 125

Epilepsy drug side effect - pheytoin

Answer 125

Ataxia Peripheral neuropathy Gum hyperplasia Hepatotoxicity

Question 126

Sodium valproate?

Answer 126

Tremor Teratogenicity Tubby (weight)

Question 127

Alzheimer's disease?

Answer 127

MIld = Acetylcholinesterase inhibitors. | - Donepezil, rivastigmine, galantamine.

Question 128

Management of Crohn's - does the question talk about inducing remission or maintaining remission?

Answer 128

Treat acute flair with prednisolone 30mg daily. Treat severe flare with hydrocortisone. 100mg 6-hourly IV. Treat rectal disease with rectal hydrocortisone.

Question 129

Maintaining remission?

Answer 129

Azathioprine is a pro-drug metabolisted to 6-merceptopurine. Therefore check TPMT levels before starting either drugs. If too low consider starting methotrexate instead.

Question 130

Giving hypnotic to patient on ward?

Answer 130

Start with zopiclone 7.5mg orally nightly in adults.

Question 131

Management for constipation in the ward?

Answer 131

Stool softener - Docusate sodium, arachis oil. Good for faecal impaction. Bulking agents - Isphagula husk. Faecal impaction, colonic atony. takes days to develop effect. Dont use in faecal impaction. Stimulant laxative - Senna, Disacodyl - Don't use in acute abdomen. Osmotic laxatives - Lactulose, phosphate enema. Don't use in acute abdomen.

Question 132

Asthma management - patient has salbutamol tremor and uses his inhaler more than 2x a week.

Answer 132

Should be stepped up to beclamethasone 200micrograms 1 puff 2x a day + counsel about salbutamol overuse. Shouldnt need to increase dose of salbutamol inhaler.

Question 133

Patient has skin infection?

Answer 133

Prescribe flucloxacillin 500mg 6 hrly for 7 days.

Question 134

Management of acute pulmonary oedema?

Answer 134

Furosemide 40mg IV

Question 135

Which two drugs are known to have antimuscarinic side effects out of - Omeprazole - Cyclizine - Amitriptyline - Ibuprofen - Enoxaparin

Answer 135

Cyclizine - antihistamine with some known antimuscarinic side effects Amitriptyline - Tricyclic antidepressant - used at lower doses to treat neuropathic pain with known antimuscarinic side effects.

Question 136

Side effects of carbimazole?

Answer 136

Drug-induced neutropenia (sore throat, bone marrow suppression) Carbamazepine can also cause neutropenia.

Question 137

Patient is ?Alzheimer's and is taking a drug that in making his symptoms of parkinson's

Answer 137

Metoclopramide and haloperidol Both can precipitate Parkinson's

Question 138

Does Domperidone cross the BBB?

Answer 138

No

Question 139

Patient with STEMI who is allergic to opioids? What painkiller do you give?

Answer 139

GTN Spray 2 puffs sublingual

Question 140

Treatment of DVT with raised D-dimer - suggestive of PE?

Answer 140

LWM heparin (enoxaparin, tinzaparin or dalteparin) TREATMENT DOSE = 15,000. Prophylaxis dose = 4,000 units daily.

Question 141

Pregnant woman asked for advice regarding HTN management ramipril during pregnancy?

Answer 141

She cannot take it during the first trimester. It is advised to convert to labetalol before conception.

Question 142

Patient with tamoxifen and is being warned of the risks?

Answer 142

Tamoxifen increases risk of VTE, and swollen leg could suggest a deep vein thrombosis which needs urgent medical attention.

Question 143

Patient on gliclazide

Answer 143

This is a sulphonylurea High risk of hypoglycaemia. Patient must not miss meals as this will increase risk of hypoglycaemia. Should not double up dose next time Missed meals do not improve blood sugar control. Taken in the morning - bedtime will increase risk of nocturnal hygoglycaemia.

Question 144

Methotrexate management for a patient?

Answer 144

Regular monitoring of WBC is required given risk of neutropenia. Methotrexate should only ever be taken once weekly. Infection risks are much higher given its effect on WBC Folate antagonists such as trimethoprim and co-trimoxazole should never been taken with methotrexate as they increase its effect. Folic acid should be used alongside methotrexate to limit its toxicity to bone marrow.

Question 145

Advice when using warfarin?

Answer 145

Warfarin carry significant risk of bleeding. Risk is reduced if the INR is regularly monitored. Alcohol affects metabolism of warfarin and makes monitoring difficult. Patients that want to drink should do it over a week, least impact on INR. Warfarin tablets are colour coded. White (0.5mg), brown (1mg), blue (3mg) and pink (5mg). Initially weekly blood tests needed then performed monthly.

Question 146

What cautions should patients be told about when going on ACEi?

Answer 146

High risk of hyperkalaemia Cough is common If patient is vomiting or diarrhoea - risk of AKI Both ACEi and diuretics can cause renal failure. It is important to monitor renal function following initiation of ACEi

Question 147

Patients on long term steroids?

Answer 147

Increases risk of DM Increase risk of osteoporosis. If taken for more than 3 months then give prophylactic treatment. Small risk of gastric irritation and gastric duodenal ulceration in steroids therapy. H2 antagonists or PPI should be considered. Never stop steroids abruptly due to risk of addisonian crisis. Patients on steroids are at risk of HTN so should be monitored regularly.

Question 148

Patient on citalopram after being diagnosed with depression? What should she know?

Answer 148

Takes 6 weeks before there is any improvement Citalopram makes you more photosensitive and precaution should be taken in sunlight. Antidepressants can still be suicidal and should seek help immediately. Furthermore a small proportion of patients will actually feel work immediately after. Symptoms of serotonin syndrome which is a life threatening complication of SSRIs. Should attend hospital immediately. SSRIs can cause a dry mouth.

Question 149

Patient with new T1DM - how should you advise her?

Answer 149

Depends on consciousness hypoglycaemia should be treated with carbs + glucose tablets. HbA1c gives an average glucose control over 3 months. Diabetic patients should target an HbA1c of 48mmol/mol or less. When unwell, increased basal dose as required. Failing this will lead to the risk of DKA. Poor glycaemic controls increase risk of microvascular and macrovascular complications. Failure to rotate injection sites can lead to lipodystrophy.

Question 150

Advice when taking bisphosphonates?

Answer 150

Reduce risk of fractures but do not prevent them. Alendronic acid is once weekly prep. Calcium salts reduce the absorption of bisphosphonates and should be taken at the same time of day. Food should be avoided 2 hrs after taking alendronic acid as it reduced absorption. Needs to be swallowed with a full glass of water and remain upright for 30 mins afterwards.

Question 151

Calculations for PSA - How many mg are in 1ml of 1% lidocaine?

Answer 151

1% means 1 in 100. 1% means 1g in 100ml. 1g in 100ml in 1ml there is 0.01g or 10mg. Therefore 2% solution contains 2g in 100ml.

Question 152

Microgram?

Answer 152

10^6

Question 153

1% means what?

Answer 153

1g in 100ml

Question 154

4ml of furosemide 50mg in 5ml is given to a patient. WHat dose has been given?

Answer 154

50mg/5ml = 10mg/1ml. Therefore 4ml x 10mg/ml = 40mg.

Question 155

Now you want to give the same patient 75mg

Answer 155

7.5ml. This is because 50mg/5ml = 10mg/ml. 75mg x 1 ml / 10 = 7.5ml.

Question 156

11 yr old girl weighing 30kg requires a 2mg/kg slow IV bolus dose of antibiotics. Ampoule contains 80mg in 2ml. What volume is required?

Answer 156

30 x 2 = 60mg | 60mg/80mg = 0.75 = 1.5ml

Question 157

When should you not give 'high dose' regimens of gentamicin?

Answer 157

When patients have a creatinine clearance of <20ml/min.

Question 158

If patient is hypernatraemic what fluid do you prescribe and how much?

Answer 158

5% Dextrose 1hr.

Question 159

Treatment prescription for Pulmonary embolism?

Answer 159

Dalteparin 15,000 units S/C OD = treatment dose. Enoxaparin 120mg or 12,000 units S/C OD. Tinzaparin 14,000 units S/C

Question 160

Dose of HF medication ACEi?

Answer 160

Enalapril 2.5mg ON starting dose. Lisinopril 2.5 ON Perinodopril erbumine 2.0 mg OD Ramipril 1.25mg ON Can cause Postural hypotension therefore given in the evening. For HTN only give ARBs if ACEi cannot be tolerated.

Question 161

First line treatment for acute asthma?

Answer 161

Salbutamol nebs 5mg STAT. Terbutaline nebs 10mg STAT - correct dose for acute asthma. Ipratropium nebs 250/500micrograms Neb STAT. Cannot be given more than 4-6/day.

Question 162

First line pain management in stable angina?

Answer 162

GTN spray Glyceryl trinitrate 2 sprays SUBLINGUAL. Remember Morphine is used for ACS.

Question 163

Patient with AF first line treatment has asthma.

Answer 163

Diltiazem - Patient has AF. Suggests he needs rate control due to his age. Give 120mg OD using modified release prep. Verapamil 40-120mg OD 8hrly. Digoxin should be used in patient whom beta or CCB is inadequate or contraindicated.

Question 164

Drug to reduce potassium in hyperkalaemia?

Answer 164

Actrapid with glucose 10 units of NOVORAPID in 100ml of 20% Dextrose over 30 mins IV. Hyperkalaemia secondary to renal failure. First potassium lowering therapy is insulin and dextrose. Insulin causes cellular uptake of potassium and then dextrose is given to prevent subsequent hypoglycemia.

Question 165

Management of focal epilepsy?

Answer 165

Lamotrigine 25mg OD PO. Lamotrigine or carbamazepine. However this causes SIADH therefore is not appropriate here as sodium would likely drop further which itself may provoke seizures.

Question 166

Patient with T2DM with high creatinine management?

Answer 166

Gliclazide 40mg OD with first meal. When selecting first oral hypoglycaemic drug for diabetic patients, generally pick metformin if overweight or a sulphonylurea if normal/underweight. A creatinine of >150 should also preclude using metformin. Could also use tolbutamide Glipizide Glimepiride

Question 167

When prescribing statins what would you check?

Answer 167

CK level baseline should be checked in patients with risk factors for muscular disorders, muscular toxicity, high alcohol intake, renal impairment, hypothyroidism and elderly. If there are no risk factors then a baseline check of CK is not most suitable, therefore check ALT. Statins are metabolised in the liver, so hepatic impairment will increase their level and risk of myopathy. If ALT or AST is raised more than 3 time normal range then statins are contraindicated.

Question 168

What to check in bloods before a patient is prescribed vancomycin?

Answer 168

Renal - serum creatinine. Clearance is reduced in patients with renal dysfunction. Must be taken into account when choosing a dosing regimen for vancomycin. Two classic side effects of vancomycin are nephrotoxicity and ototoxicity.

Question 169

Phenytoin levels?

Answer 169

If pre-dose trough is within normal range? If there are no seizures then yes must be normal and within range.

Question 170

Monitoring lithium levels?

Answer 170

Sampling time for lithium is 12hr after last dose. Normal reference range is 0.4-0.8mmol/l and toxic effects manifest over 1.5mmol/L. FBC are not routine in patient on lithium. Routine lithium is performed weekly after initiation and after each dose change until concentrations are stable. Then every 3 months. Sodium depletion is known to increase the risk of lithium toxicity and patients are advised to avoid making changes in their diet that would lead to increased or decreased sodium intake.

Question 171

Monitoring methotrexate levels

Answer 171

Known to cause fatal blood dyscrasias. Monitor FBC ar regular intervals is imperative, but once therapy has been stabilised, FBC can be monitored every 2-3 months. According to BNF, CXR is not required, but may be required later on if pulmonary toxicity is suspected. Due to liver cirrhosis risk, methotrexate should not be started if liver function tests are abnormal. If sudden drop in WBC or platelets - Methotrexate should be reduced. Methotrexate is predominately renally excreted and toxicity is more likely in presence of renal dysfunction.

Question 172

What to monitor on a patient with olanzapine?

Answer 172

Hyperglycaemia and diabetes can occur in patients prescribed antipsychotic drugs, particularly olanzapine. Fasting blood glucose must be tested at baseline and at regular intervals thereafter. Baseline ECG prior to commencing an antipsychotic drug is only usually indicated in patients with CVS or associated risk factors. §

Question 173

What to check in a patient being prescribed the OCP?

Answer 173

HTN is known to increase risk of arterial disease associated with contraceptive medication.

Question 174

When monitoring patients on amiodarone?

Answer 174

T3, T4 and TSH must all be included in a measurement of thyroid function in patients taking amiodarone. T4 may be raised in absence of hyperthyroidism. Check X-ray owing to risk of pulmonary toxicity with amiodarone. Monitor Transaminases throughout duration of therapy.

Question 175

Patients with carbimazole?

Answer 175

If evidence of sore throat check FBC and neutrophil count. | This is due to carbimazole-induced bone marrow suppression and thus agranulocytosis.

Question 176

Gentamicin regime for multiple daily dose?

Answer 176

1hr peak serum concentration should be 3-5mg/L for the treatment of endocarditis. Both pre and post dose levels must be checked at regular intervals. Principally excreted renally. Patients with renal dysfunction are at increased risk of toxicity thus monitoring of renal function is required at regular intervals in patients on gentamicin.

Question 177

Monitoring of ACEi?

Answer 177

ACEi are known to cause hyperkalemia, hyponatraemia and in some cases AKI. U+E checked at baseline and after every dose.

Question 178

Monitoring Digoxin levels?

Answer 178

Predominantly renally excreted and patients with renal dysfunction are at increased risk of toxicity. Plasma digoxin concentration is not measured unless toxicity, non compliance or inadequate effect are suspected.

Question 179

Sodium valproate monitoring?

Answer 179

Associated with hepatotoxicity and liver function should be measured at baseline as well as regular intervals through therapy.

Question 180

Monitoring on clozapine?

Answer 180

Owing to risk of neutropenia and potential fatal agranulocytosis, routine monitoring of full blood count is required at regular intervals as dictated by product licence.

Question 181

Side effects of gentamicin and vancomycin?

Answer 181

Nephrotoxicity | Ototoxicity

Question 182

Side effects of general antibiotics (mainly cephalosporins and ciprofloxacin)?

Answer 182

C diff

Question 183

Side effects of ACEi?

Answer 183

Hypotension Electrolyte abnormalities AKI Dry cough

Question 184

Side effects of Beta-blockers?

Answer 184

Hypotension Bradycardia Wheeze in asthmatics Worsens acute heart failure

Question 185

Side effects of CCBS?

Answer 185

Hypotension Bradycardia Peripheral oedema Flushing

Question 186

Side effects of diuretics?

Answer 186

Hypotension Electrolyte abnormalities AKI

Question 187

Side effects of heparin?

Answer 187

Haemorrhage, thrombocytopaenia (Heparin induced)

Question 188

Side effects of warfarin?

Answer 188

Haemorrhage - does take a few days to become an anticoagulant. Therefore prescribe warfarin and continue until INR exceeds 2.

Question 189

Digoxin antiarrhythmics SE?

Answer 189

``` Nausea, vomiting, diarrhoea. Blurred vision Confusion Drowsiness Xanthopsia (yellow/visual perception and halo vision). ``` Digoxin compete with K at the myocyte, limiting Na influx. Since Ca outflow relies on NA influx, Ca accumulates in the cell. This lengthens action potential and slows heart rate. Therefore low K augments digoxin effects. High levels of K limit effect. This is because K competes with digoxin at the receptor

Question 190

SE of amiodarone?

Answer 190

``` Interstitial lung disease Thyroid disease Hyperthyroidism Structure related to iodine therefore amIODarone. Skin greying COrneal deposit. ```

Question 191

Lithium side effects?

Answer 191

Early - tremor Intermediate - tiredness Late - arrhythmias, seizures, coma, renal failure, diabetes insipidus.

Question 192

Antipsychotic side effects?

Answer 192

Haloperidol - Dyskinesias e.g acute dystonic reactions. Clozapine - Agranulocytosis - requires intensive monitoring of full blood count.

Question 193

Corticosteroids side effects?

Answer 193

Dexamethasone and prednisolone - Stomach ulcers - Thin skin - Oedema - Right and left heart failure - Osteoporosis - Infection - Diabetes - Cushing's syndrome Fludrocortisone - HTN, salt/water retention

Question 194

NSAIDS SE?

Answer 194

NSAID - No urine (renal failure) - Systolic dysfunction ( heart failure) - Asthma - Indigestion - Dyscrasia (clotting abnormality)

Question 195

Statins SE?

Answer 195

Simvastatin - Myalgia - Abdo pain - Increased ALT/AST - Rhabdomyolysis

Question 196

Types of drugs that interact?

Answer 196

Drugs with a narrow therapeutic index = warfarin, digoxin, phenytoin. Can lead to toxic or therapeutic levels. Drugs that require careful titration of dose according to effect - anti-HTN, anti-diabetic. Iodinated contrast media can cause renal impairment, which increases risk of metformin-induced lactic acidosis or ACEi AKI. Drugs that affect P450 enzyme.

Question 197

Drugs with potent interactions with alcohol?

Answer 197

GI bleeding caused by - NSAIDS (aspirin and ibuprofen) Lactic acidosis caused by metformin Increased anticoagulation caused by: warfarin (with acute alcohol due to enzyme inhibition (acute alcohol dues enzyme inhibition). Chronic alcohol caused enzyme induction and thus reduced anticoagulant effect. HTN crisis: Monoamine oxidase inhibitors and alcohol. Sweating, flushing, nausea and vomiting: metronidazole and disulfiram with alcohol Sedation caused by: barbiturates, opioids and benzodiazepines.

Question 198

What blood to check when monitoring ACEi?

Answer 198

Serum potassium!! Should also check serum creatinine. Potassium more important than sodium as it can cause arrhythmias.

Question 199

What are the side effects of beta-blockers?

Answer 199

Associated with cold extremities Treat tremor. Likely to cause hypotension

Question 200

Drugs known to cause peptic ulcers?

Answer 200

NSAIDS | Steroids

Question 201

What can diclofenac cause?

Answer 201

Do not co-prescribe NSAIDS and ACEi.

Question 202

Why not prescribe trimethoprim with methotrexate?

Answer 202

Both are folate antagonist. Lead to additive toxicity in the form of bone marrow suppression, pancytopenia and neutropenic sepsis.

Question 203

What is amiloride?

Answer 203

It is a potassium sparing diuretic causing hyperkalaemia. ACEi also cause hyperkalaemia.

Question 204

Erythromycin and warfarin?

Answer 204

CYP450 inhibitor = longer bleeding. Cipro and warfarin also interact.

Question 205

Management of INR 8 with minor bleeding.

Answer 205

Give IV Vit K via a slow injection. REMEMBER PROTAMINE REVERSES EFFECTS OF HEPARIN.

Question 206

Patient with anaphylaxis what do you do first?

Answer 206

Secure the airway - patient will not benefit much from a non-patent airway.

Question 207

Management of drug-induced hypoglycaemia?

Answer 207

A conscious patient should be given 10-20G of glucose by mouth. Drug-induced hypoglycaemia should be managed in hospitals as the hypoglycaemic effects of these drugs can persist for many hours. Glucagon is used in the unconscious patient. Metformin is less likely to cause hypoglycaemia than sulphonylureas.

Question 208

How does metformin work

Answer 208

Biguanide - Limiting hepatic gluconeogenesis. Lacrate is usually taken up by this process, without new sugar production in the liver has a build up of lactic acidosis. Sulphonylureas squeeze insulin out of the pancreas. Therefore these are more dangerous as they act directly on insulin levels.

Question 209

Drugs to stop before surgery

Answer 209

Stop Aspirin, heparin and contraceptive pill. Metformin is stopped day before surgery, due to risk of lactic acidosis. Insulin should be stopped and converted to a sliding scale. DO NOT STOP BB or CCBs.

Question 210

What if you see tamoxifen in a man's drug chart?

Answer 210

Highly likely a mistake.

Question 211

What is the daily dose of alendronic acid?

Answer 211

10mg

Question 212

What is the prophylactic dose of aspirin?

Answer 212

75mg Treatment is 300mg.

Question 213

When in renal failure what should be withheld?

Answer 213

Ibuprofen Lisinopril. Aspirin does NOT cause renal failure so should be continued.

Question 214

What can bendroflumethiazide cause?

Answer 214

Gout

Question 215

Check UNITS OF STUFF!!!

Answer 215

Check units of enoxaparin against weight Check paracetamol dose.

Question 216

What can affect lithium excretion and contribute to toxicity

Answer 216

Enzyme inhibitors ACEi - lisinopril Diuretics - thiazide and bendroflumethiazide

Question 217

How to adjust levothyroxine if a patient is receiving too much? (Low TSH)

Answer 217

25-50 decrease.

Question 218

if you have a hypernatraemia what fluids?

Answer 218

5% glucose. Patients that is losing 1L every 4hrs input should be matched.

Question 219

Maintenance fluid for people and what bags?

Answer 219

1 salty 2 sweet. 8hrly. Equating to 3L.

Question 220

Key tip for a abnormal isolated hyperkalaemia?

Answer 220

Interprete in the context of the patient's condition.

Question 221

When is metformin contraindicated?

Answer 221

IN patients with an eGFR of <30 and should be used with caution if <45. Risk of lactic acidosis.

Question 222

What is ondansetron?

Answer 222

5HT3 antagonist treatment of nausea. | Chemically induced nausea including chemotherapy.

Question 223

When is haloperidol used?

Answer 223

Dopamine antagonist used in palliative care.

Question 224

Where is metoclopramide used?

Answer 224

It is a prokinetic antiemetic therefore CONTRAINDICATED in bowel obstruction.

Question 225

Management of COPD?

Answer 225

Give Salbutamol nebs Ipratropium bromide 500micrograms NEB Steroids are later as they take time.

Question 226

Patient has non-responsive hypotension? Which fluid>

Answer 226

Fluid challenge of 500ml gelofusine IV over 30 mins?

Question 227

Anaphylaxis management?

Answer 227

1:1000 Adrenaline IV Steroids - Hydrocortisone and IV antihistamine Fluid resus happens much quicker.

Question 228

Angioedema in ACEi?

Answer 228

Delayed and over months later.

Question 229

When are ACEi blood test done?

Answer 229

Renal function and K essential assessment - 1-2 weeks after initiation.

Question 230

What is the interaction of statins and clarithyromycin?

Answer 230

They increase toxicity and are CTP450 inhibitors. Increase associated side effects. Statins taken overnight as cholesterol metabolism occurs overnight.

Question 231

Immediate relief from dyspepsia?

Answer 231

Antacids - Magnesium carbonate 10ml oral - Aluminium hydroxide 1 capsule oral - Co-magaldrox 10ml

Question 232

When do you give heparin in the day?

Answer 232

18:00

Question 233

When prescribing antibiotics what must you ensure?

Answer 233

That you have a stop date. PRevents unnecessarily long antibiotic courses.

Question 234

Painkillers - As required or Regular?

Answer 234

If patient is currently pain free put it into as required. Codeine is contraindicated in primary headaches as they can actually make them worse.

Question 235

First line for hospital acquired pneumonia?

Answer 235

Piperacillin/Tazobactam.

Question 236

Patient wants a laxative as she has not opened her bowels for 4 days. She is now mobilising, but you attribute her constipation to recent immobility. Feels bloated + denies cramps.

Answer 236

Give a stimulant laxative - an appropriate (no colitis or cramps which are the main contraindication) . Give Senna Disacodyl Give it at night time.

Question 237

Typical opioid side effects?

Answer 237

Respiratory depression Reduced consciousness Pinpoint pupils Tramadol - Agitation Hallucinations

Question 238

When you are monitoring the effect of aminophylline on an acute asthma station what are you looking at?

Answer 238

Oxygen saturation

Question 239

When you have a pneumonia, what are looking at to judge an improvement?

Answer 239

Successful treatment of pneumonia will improve gas exchange, hypoxia, therefore the respiratory rate. If oxygen sats or ABG were options these would be more accurate and specific. Consolidation in an X-ray will take weeks to resolve.

Question 240

How to measure the tacrolimus level?

Answer 240

Morning or evening dose. Aim for a level of 6-12. Tacrolimus can manifest as tremor.

Question 241

How to monitor if a DKA has resolved?

Answer 241

Glucose normalised rapidly after commencing an insulin sliding scale. But this does not necessarily suggest resolution of DKA. Normalisation of serum ketones suggest cessation of ketogenesis and therefore accurate reflection of response to treatment.

Question 242

How best to monitor COPD patients?

Answer 242

Pulse oximetry? | - Target of 88-92%.

Question 243

Vancomycin trough?

Answer 243

Pre-dose vancomycin should be 10-15mg/L. The reported level is within this range so it would be appropriate to assume, that no dose change is required.

Question 244

What drug class causes facial flushing?

Answer 244

CCB - Amlodipine

Question 245

COPD first line?

Answer 245

Remember patient has inhalers but you MUST switch this to NEBULISERS. Eg Terbutaline sulphate 2.5mg/ml nebuliser. Salbutamol 2mg/ml nebuliser liquid.

Question 246

DVT 1st line treatment of DVT/PE?

Answer 246

LMWH or fondaparinux? Enoxaparin 1.5mg/kg SC daily. Contraindicated with patients with heparin-induced thrombocytopenia, or acute haemorrhage. LMWH generally preferred over unfractionated heparin in treatment of DVT and PE except in case of significant renal impairment where unfractionated heparin may be preferable.

Question 247

Fluid for a patient with elevated glucose (7.2) with current previous stroke not dehydrated, borderline sodium.

Answer 247

Sodium chloride 0.9% Patient is unable to hydrate or nourish themselves. Needs maintenance water, electrolytes and nutrition delivered by IV route. May be depleted indicated by high sodium and urea although BP and HR do not give immediate cause for concern. No need for rapid fluid replacement. Appropriate infusion would be a 500ml over 4- 6hrs or 1l over 8-12hrs.

Question 248

Statin as a choice for lowering LDL cholesterol?

Answer 248

NICE suggests to offer statins to those with a 10yr risk of CVS disease of 10% or more. Given once daily at night. Associated with myaglia (Risk of myopathy, myositis, rhabdomyolysis associated with statin use is rare).

Question 249

Drugs that can irritate the gastric mucosa?

Answer 249

NSAIDS - ibuprofen and aspirin.

Question 250

Drugs that can damage the kidney?

Answer 250

Ibuprofen ACEi NB: Digoxin is largely cleared by kidney and accumulate in renal impairment but is not usually a cause of decreased renal function.

Question 251

Drugs that can contribute to dehydration?

Answer 251

Bendroflumethiazide | Spironolactone

Question 252

When is Metformin contraindicated in patients?

Answer 252

With significant renal impairment

Question 253

Which antidiabetic can cause hypoglycaemia?

Answer 253

Thiazolidediones - Pioglitazone | Sulphonylureas.

Question 254

Causes of urinary retention?

Answer 254

Morphine sulphate - common in early postoperative period. Other drugs - Anticholingerics (antipsychotics, antidepressants, anticholinergics, detrusor relaxants) - General anaesthetics - Alpha-adrenoceptor agonist - Benzodiazepines - NSAIDS - CCBs - Antihistamines

Question 255

Drugs that cause confusion

Answer 255

Metoclopramide Morphine - Others = anticholingerics, antipsychotics, antidepressants, anticonvulsants, H2 receptor antagonist, digoxin, B-blockers, Corticosteroids, NSAIDs. Eg Fentanyl Temazepam Trazodone.

Question 256

Management of a patient with longstanding alcohol abuse?

Answer 256

IV Vit B - risk of Wernicke's encephalopathy. Even if he's on the tablets doesn't mean there is any guarantee that he will be taking them.

Question 257

DKA management?

Answer 257

Fluids - NaCl 0.9% IV infusion over 1hr. Then insulin 50 units in NaCl normally in 0.1 units/kg/h.

Question 258

Patient under 55 with HTN and presence of LVH?

Answer 258

ACEi as justified treatment of his BP.

Question 259

Management for prevention of neural tube defects?

Answer 259

Folic acid 5mg PO daily. High risk of conceiving a child with neural tube defects. Those at low risk should take folic acid at a lower dose of 400 micrograms

Question 260

Alendronic acid advice?

Answer 260

Has been shown to reduce fractures, widely prescribed prophylaxis in patients with osteoporosis

Question 261

What should patients be warned about when taking Gliclazide?

Answer 261

Take precautions for hypoglycaemia = take a source of sugar with them.

Question 262

HRT management in patients?

Answer 262

For women with an intact uterus, oestogren is a combined with a progesterone which reduced risk of endometrial carcinoma with unopposed oestrogen.

Question 263

An 85-year-old man on the coronary care unit is being treated for angina. He requires treatment with isosorbide dinitrate 0.1% solution by IV infusion via an infusion pump at a rate of 2.5 mg/h. At what rate of delivery (mL/h) should the infusion pump be set?

Answer 263

Concentration of solution is 0.1% Therefore 0.1g per 100ml.

Question 264

Common side effect of methotrexate?

Answer 264

Leucopenia - therefore requires monitoring with regular FBCs.

Question 265

Management of anaphylaxis?

Answer 265

NSAIDS are most frequent in causing hypersensitivity reactions Give IM 0.5ml of a 1 in 1000 solution Other that can cause it are - B-lactam antibiotics, aspirin, NSAIDs, chemo, vaccines

Question 266

How to monitor allopurinol's therapeutic effect?

Answer 266

Aims to reduce serum urate. Inhibits activity of enzyme xanthine oxidase.

Question 267

Assessment of a hydrated patient's rehydration?

Answer 267

Measure with Low BP

Question 268

What can lithium affect in bloods?

Answer 268

Renal function - monitor with renal function tests. Can also cause nephrotic syndrome and nephrogenic DI.

Question 269

Measuring adverse affect of HRT?

Answer 269

BP - Can cause sodium and fluid retention - leading to a rise in BP. Stop HRT if the bp rises above Systolic 160mmHg and diastolic 95.

Question 270

Simvastatin with a raised ALT (double)

Answer 270

The ALT is slightly raised but is not an indication to reduce or stop therapy, even if it is related to simvastatin. Current guidance suggests that liver enzymes should be measured before treatment, and repeated within 3 months and at 12 months of starting treatment, (unless indicated at other times by signs or symptoms). Patients with serum transaminases that are raised, but less than 3 times the upper limit of the reference range, should not be routinely excluded from statin therapy. Those with serum transaminases of more than 3 times the upper limit of the reference range should discontinue statin therapy.

Question 271

Gentamicin monitoring?

Answer 271

The dose is the major determinant of the peak concentration post-dose and needs to be reduced in view of the high peak concentration. It is also appropriate to extend the dose interval to allow more time for the gentamicin to be cleared and achieve a lower trough. The trough concentration indicates the concentration to which potential targets of toxicity (e.g. ear and kidney) are constantly exposed.

Question 272

Patient with SOB and oedema 1 week. IHD, T2DM, CKD, ulcers, gout. Biphasic isophane insulin. 16units bisoprolol fumarate 2.5 PO daily. Alfacalcidol 500 micrograms, allopurinol 100mg PO daily, clopidogrel, enalapril, isosorbide mononitrate, nicorandil 12 hrly. On exam - Temp 37.1, regular BP 160/92, JVP raised, RR 22, 94% O2, bilateral pitting leg oedema. Best drug to alleviate breathlessness?

Answer 272

Patient has pulmonary oedema - required immediate treatment. Loop diuretics and first line and furosemide is optimal choice as it can be given IV. Correct dose is 20-50mg IV as a once only dose. Doses below 20 score zero. Doses above 50mg up to 100mg would be effective but unnecessarily high. Furosemide 10mg/ml injection. Pulmonary oedema which requires immediate treatment.

Question 273

Total hip replacement 12 hrs ago. One drug that is most appropriate for VTE prophylaxis?

Answer 273

VTE prophylaxis LMWH for 10 days followed by aspirin for further 28 days. LMWH for 20 days combined with Anti TEDs. Try enoxaparin sodium 100mg/ml injection.

Question 274

74 yr old being treated on medical ward for AKI. Hypoglycaemic? One IV Fluid that is most appropriate to treat his current condition .

Answer 274

20% glucose solution. 50ml IV Over 10-20 mins or less. Need to deliver this urgently

Question 275

14 yr old boy visits his GP. Concerns about acne. Clinda topical, previously benzoyl peroxide. Erythromycin for throat infection causes nausea.

Answer 275

Need to offer oral antibiotics. This can be tetracycline, oxytetracycline, doxycycline or lymecycline.

Question 276

Drugs contributing to hyperkalaemia?

Answer 276

Ramipril Tacrolimus Heparins - Contribute to hyperkalaemia because of inhibition of aldosterone synthesis.

Question 277

One drug to stop 1 week prior to surgery?

Answer 277

Antiplatelet agents usually stopped 7 days before surgery.

Question 278

Drugs to withhold until renal function recovers?

Answer 278

Allopurinol - can accumulate in renal dysfunction - BNF advises max daily dose 100 mg until renal function improves. Candesartan

Question 279

Drugs contributing to confusion?

Answer 279

co-codamol Diazepam Prednisolone

Question 280

Drugs contributing to hyperglycaemia?

Answer 280

Prednisolone - stress response to hyperglycaemia.

Question 281

Drugs contributing to hyponatraemia?

Answer 281

Bendroflummethiazide | Citalopram (SIADH)

Question 282

Patient has mets in breast, depression + osteoporosis. Currently on fentanyl 50 micrograms transdermal patch one patch applied 72hr daily + gabapentin. Wants more pain killers?

Answer 282

Give fentanyl 50 micrograms/actuation nasal spray to one nostril repeated once after 10 mins as required. Patients receiving at least 25 micrograms of transfermal fentayl per hour can use nasal fentanyl for breakthrough pain. Max dose is 50 micrograms into one nostril. repeat once if necessary after 10 mins with max of two

Question 283

When to avoid prescribing nitrofurantoin?

Answer 283

If eGFR is less than 45 ml. May be used with caution if eGFR 30-44 as a short course. Treat uncomplicated LUTI. Try trimethoprim as an alternative. 7 day courses in males!

Question 284

Alcohol withdrawal medications?

Answer 284

Chlordiazepoxide

Question 285

If INR is >1.5 before surgery what medicine should be given?

Answer 285

Phytomenadione/ Vitamin K. Warfarin should be stopped 5 days.

Question 286

Patient about to start SSRI what should he be warned about the MOST?

Answer 286

Suicidal ideation may worsen in first 4 weeks.

Question 287

Most important info for patient on rivaroxaban?

Answer 287

Should be taken with food.

Question 288

Patient has migraines, advised to take topiramate, to control symptoms. She is also taking desogetrel? Most important information option to provide her regarding her contraception?

Answer 288

She should change to an alternative method of contraception until 4 weeks after she has ceased topiramate. Efficacy of oral progesterone-only prep is reduced by enzyme inducing drugs like topiramate. An alternative method of contraception should be used.

Question 289

What are the most likely side effects of beta blockers?

Answer 289

Sexual dysfunction (erectile dysfunction)

Question 290

Cholestatic jaundice?

Answer 290

Due to co-amoxiclav. More common in men over 65.

Question 291

Which drug is most likely to interact with dabigatran etexilate to cause GI bleed?

Answer 291

Citalopram

Question 292

Patient is given furosemide for flash pulmonary oedema? how do you monitor beneficial effects after 2 days?

Answer 292

Weight is the best.

Question 293

What to look at when monitoring side effects for carbimazole?

Answer 293

FBC - due to neutropenia.

Question 294

Patient on ACEi - what is the most appropriate to monitor beneficial effects of it?

Answer 294

Exercise tolerance - indicates that the treatment is working.

Question 295

Patient has lupus - most appropriate option to monitor adverse effects of ciclosporin after 2 weeks?

Answer 295

Ciclosporin is nephrotoxic and HTN are thought to be mediated by this .

Question 296

Patient with acute neck spasm and painful eyes? Best management to treat his eye and neck spasm?

Answer 296

Antimuscarinic drugs are first line to treating acute dystonic reactions. Procyclidine hydrochloride 5mg/ml. Give parenterally as PO may have an unsafe swallow.

Question 297

Woman with COPD - worsening breathlessness and non-productive cough. Temp 37, HR 90, BP 148, RR 18, O2 88%. Already been given Ipratropium bromide/salbutamol 2.5. What additional drug do you need to give?

Answer 297

Prednisolone 5mg tablet equating to 30mg PO daily.

Question 298

Patient already prescribed 2L of NaCL 0.9% in the last 24hrs. What fluid to prescribe now? 80 kg man.

Answer 298

He needs 80mmol of Na and 80 mmol of. Do not give another sodium bag. Give 5% glucose (as glucose is in normal range). Approprioate infusion rate is 2000-2400ml day (80-100ml/h). He needs 80 mmol K+ per day so 40 mmol/L KCL in the next bag.

Question 299

Fluid requirements daily?

Answer 299

25-30ml/kg/day 1mmol of K, Na, Ch 50-100g/day of glucose.

Question 300

How much does a bag of NaCL contain?

Answer 300

``` Sodium = 150 Chloride = 150 ``` Must have glucose in the day!

Question 301

55 yr old woman presents to her GP for a review of her current HRT. Wants an alternative preparation that will not give her monthly withdrawal bleeds. Wants a transdermal preparation.

Answer 301

Search for continuous patches A product containing both oestrogen and progestogen is required. The oestrogen will control the hormonal symptoms and the progestogen is required as she has a uterus, to proect against the risk of endometrial cancer, from unopposed oestrogen. A product that releases the same dose continuously, rather than a sequential product, will avoid withdrawal bleeding. The patient's preference is for a transdermal patch, rather than a tablet formulation. levonorgestrel 7 micrograms/estradiol 50 micrograms/24 hours transdermal weekly patch OR estradiol 50 micrograms/norethisterone acetate 170 micrograms/24 hours transdermal twice weekly patch

Question 302

What drug to avoid in peripheral vascular disease?

Answer 302

B-blockers can cause peripheral vasoconstriction and worsen ischaemia.

Question 303

Drugs likely to contribute to exacerbation of biventricular failure

Answer 303

Diltiazem (CCB) | Prednisolone (Steroid)

Question 304

Hyperkalaemia?

Answer 304

``` ACEi Aldosterone inhibitor (Spiro) ```

Question 305

Drugs contributing to vaginal candida?

Answer 305

Amoxicillin 500mg Clarithromycin 250mg oral Prednisolone 10mg oral Antibiotics are more likely to contribute to thrust.

Question 306

Which drug is important not to abruptly stop?

Answer 306

Prednisolone due to chronic adrenal suppression.

Question 307

Which drug most likely to cause a cough?

Answer 307

Ramipril

Question 308

If you want to improve a patient's morning dose of insulin?

Answer 308

Increase Novomix dose - breakfast biphasic insulin dose to 48.

Question 309

Patient has +ve nitrate, leucocyte and blood in urine. UTI treatment?

Answer 309

Give nitrofurantoin - avoid trimethoprim.

Question 310

Scarlet fever? - Macular red rash, strawberry tongue, red throat, fever >38.3).

Answer 310

Needs antibiotic treatment. Phenoxymethylpenicillin

Question 311

Patient has clarithromycin and warfarin INR is 3.3?

Answer 311

Leave dose as it is as clarithromycin will likely increase it. This is correct. Her INR is in range for the indication. For a mechanical heart valve target INR is 3.5 (range 3–4). Whilst she is currently in therapeutic range, she still requires close monitoring because of the interacting clarithromycin, which can prolong the effects of warfarin leading to a rise in INR. It is sufficient to recheck INR in 48 hours.

Question 312

How should eplerenone be monitored?

Answer 312

K-sparing diuretic and therefore hyperkalaemia. Serum potassium should be monitored during initiation, especially in at-risk groups. (Elderly, CKD, DM).

Question 313

Warn a man starting methotrexate

Answer 313

Effective contraception should be used whilst he is taking methotrexate and for at least 3 months after stopping treatment.

Question 314

Side-effects of mirtazapine

Answer 314

Causes abnormal dreams very commonly.

Question 315

Indapamide?

Answer 315

Thiazide-like diuretic causing hypokalaemia.

Question 316

Interaction of simvastatin and gemfibrozil?

Answer 316

Gemfibrozil is known to interact with simvastatin and increases the risk of simvastatin-associated severe myopathy and rhabdomyolysis. Therefore, concomitant use should be avoided. Gemfibrozil significantly increases simvastatin acid plasma concentrations, probably because of inhibition of simvastatin acid uptake by the hepatic sinusoidal xenobiotic uptake transporter OATP1B1. Gemfibrozil is also a potent mechanism-based inhibitor of CYP2C8.

Question 317

Unconscious patient that is hypoglycaemic?

Answer 317

Give Glucose 20% 75 ml. Admin of 15g of glucose using a 20% solution is correct treatment of hypoglycaemia.

Question 318

Beta blocker therapy in AF - response to treatment?

Answer 318

HR

Question 319

Amiodarone monitoring option

Answer 319

Hypokalaemia is a caution for amiodarone.

Question 320

Any regular monitoring for sertraline?

Answer 320

May cause hyponatraemia. | No routine blood monitoring

Question 321

Patient with catheter associated urinary sepsis - best way to monitor benefical effects?

Answer 321

Resolution of acute symptoms over next 72 hrs.

Question 322

Statin suspected of causing myopathy and CK is raised (more than 5x)

Answer 322

If symptoms resolve - creatinine kinase levels return to normal - statin should be reintroduced at a lower dose.

Question 323

Patient is taking 180mg of morphine PO daily. What is this equivalent to?

Answer 323

75micrograms daily.

Question 324

Patient undergoes elective cholecystectomy. On return she feels nauseated and vomited twice. Most appropriate medication to alleviate nausea?

Answer 324

Post-operative nausea From choice of droperidol, dexamethasone, prochlorperazine all cause QT prolongation therefore need to use cyclizine. Administer 25-50mg via parenteral route (IM, IV, S/C). Woman has a cannula therefore IV is preferable.

Question 325

Patient has painful rash on right side of face. Has breast cancer. Demarcated vesicular rash in the mandibular region of right side of her face.

Answer 325

Case of shingles, don't need it to be IV therefore PO.

Question 326

Patient presents with 3 day history of vomiting and gastritis. HR 115, BP 100/50/ JVP not raised RR 21.

Answer 326

This patient is dehydrated and shocked. A fluid bolus of 500ml crystalloid over 15 mins is recommended. E.g NaCl 500ml in 15 mins. Can consider hartman's/PLasma-lyte.

Question 327

Patient with Type 2 Diabetes what is first line treatment?

Answer 327

Metformin 500mg Start low to minimise effects.

Question 328

What drugs can cause hyperkalaemia?

Answer 328

Ciclosporin and eplerenone.

Question 329

Drugs contributing to dyspepsia?

Answer 329

Alendronic acid | Prednisolone

Question 330

Drugs causing loose stools?

Answer 330

Alendronic acid | Lansoprazole (All PPI)

Question 331

Drugs that cause ankle swelling?

Answer 331

Amlodipine | NSAIDs - Naproxen

Question 332

Drugs that cause bradycardia?

Answer 332

Digoxin | Bisoprolol

Question 333

Pregnancy woman with vulvovaginal candidiasis?

Answer 333

Clotrimazole pessary - systemic therapy is not recommended during pregnancy.

Question 334

Management of C.difficile?

Answer 334

First episode = mild or moderate = oral metro for 10-14 days. Second episode or for severe infection or not responding to metronidazole. = Vancomycin.

Question 335

Long-acting insulin therapy/

Answer 335

Insulin Glargine | Insulin Determir

Question 336

Management of DKA with current insulin (both long and short-term).

Answer 336

Restore SBP if below 90 with 500ml NaCl over 10-15 mins. When over 90 give NaCl 0.9 maintenance. Include KCl. Then start IV soluble insulin infusion 0.1 units/kg/hr fixed rate. Established subcut therapy with long-acting insulin analogues.

Question 337

Patient has post-herpetic neuralgia what is first line?

Answer 337

Paracetamol (in an elderly person who may be vulnerable to adverse effects). Amitriptyline is useful for second line or unresponsive to simpler measures.

Question 338

Most important information for loperamide hydrochloride?

Answer 338

Take after each loose stool.

Question 339

SSRI advice?

Answer 339

Patient must realise that the medicine must be taken regularly but that it make take several weeks before any positive benefit is likely to be seen.

Question 340

Advice for patient taking ciclosporin?

Answer 340

Regular monitoring of kidney function is required. Nephrotoxicity is a well-known adverse effect of ciclosporin therapy. Renal function measurements are required before starting ciclosporin.

Question 341

What are the adverse effects of GLP 1 analogues?

Answer 341

Vomiting

Question 342

Which drug when taken with citalopram has the increased risk of causing serotonin syndrome?

Answer 342

Tramadol

Question 343

Drug that interacts with Microgynon to reduce effect of contraceptive effect?

Answer 343

Rifampicin

Question 344

Anti-psychotic-induced parkinsonism

Answer 344

Procyclidine

Question 345

Best way to monitor adverse effect of COCP?

Answer 345

Blood pressure. | COCP can increased BP

Question 346

What to monitor with azathioprine before treatment?

Answer 346

Measure thiopurine methytransferase.

Question 347

Patient started on furosemide? Best way to assess beneficial effects of this treatment?

Answer 347

Weight.

Question 348

Patients with apixaban - best way to monitor adverse effects?

Answer 348

Patients should be informed when starting that they should report any bruising or other signs immediately.

Question 349

Patient develops signs of opioid toxicity on morphine?

Answer 349

- oxycodone is metabolised by the liver to inactive metabolites. Therefore it is good in the context of those with renal impairment. Switch to oxycodone.

Question 350

Patient on warfarin is shocked with an INR of 10?

Answer 350

Dried prothrombin complex.

Question 351

Patient with a very high T4 on amiodarone?

Answer 351

TFTs suggest development of thyrotoxicosis - therefore amiodarone should be withdrawn to achieve control.

Question 352

Patient needs fluids. Is currently hypokalaemic and therefore needs replacement of potassium as well. If she has had losses then give 4-6 litres. Need to give more.

Answer 352

Give NaCl 0.9% 1L in 4-6hr but also replace K+ with KCL 40mmol 0.3%. If hypokalaemia likely to need max 40mmol in 4hrs.

Question 353

Need to give propranolol over split doses, not 1 big dose.

Answer 353

therefore 40mg BD.

Question 354

Medications contraindicated with Parkinson's Disease?

Answer 354

Haloperiodol and antipsychotics Metoclopramide. Others that increase risk of acute dystonic reactions - Antipsychotic drugs - Metoclopramide - Domperidone - Cyclizine

Question 355

Drugs that require specific timings?

Answer 355

Parkinson's disease Myasthenia Gravis Diuretics

Question 356

Drugs depending on night time?

Answer 356

Night sedation | Less crucially statins

Question 357

Drugs relating to other medications/stomach

Answer 357

Bisphosphonates | Antacids

Question 358

Relating to mealtimes

Answer 358

Hypoglycaemics | Pancreatic enzymes

Question 359

Relating to days of the weeks?

Answer 359

Patches Bisphosphonates Methotrexate

Question 360

Opiates needs to be used with caution in patients with hepatic cirrhosis?

Answer 360

Drowsiness = Morphine Bleeding = Naproxen Renal impairment Constipation

Question 361

Patient needs increasing of dose for heart failure?

Answer 361

ACEi | Bisoprolol

Question 362

Drugs that are nephrotoxins?

Answer 362

``` Diuretics ACEi/ARBS NSAIDS Aspirin Statins and fibrates Anti-infectives (aminoglycosides, vancomycin, penicillins, intravenous anti-fungals) Radiocontrast Lithium in overdose ```

Question 363

Fluid for resuscitations?

Answer 363

Need for hypotension Tachycardia Reduced capillary refill Other evidence of hypovolaemia Use crystalloids that contain sodium in the range 130-154 - 0.9% NaCl. Bolus of 500ml over less than 15 mins

Question 364

Which fluid for regular maintenance?

Answer 364

1L of NaCl 0.9% over 8hr/12hrs alongside KCl 0.15/0.3%.

Question 365

Patient has already had a bag of sodium. Therefore they have had 154 mmol of NaCl, what is the next prescription

Answer 365

Given them 154 mmol of Na and Cl. This man needs glucose therefore 5% glucose. He has had some potassium (40mol) therefore needs some more. Therefore 5% glucose with 0.15% potassium chloride over 12hrs.

Question 366

Patient has been vomiting and diarrhoea for the past 2 days. Currently hypokalaemic but not tachy or hypo.

Answer 366

Has ongoing losses that need to be replaced. Therefore will require around 4-6 L over first day. Therefore 1L over 4-6 hrs. Will need sodium/Chloride and potassium. Has not has any potassium but has lost 140 mmol. Will need to replace glucose as some point too. Give potassium at the fastest rate you can (10mmol an hour).

Question 367

Patient has only had 1 bag of 5% glucose. Therefore he has had no sodium, chloride or glucose?

Answer 367

Therefore give NaCl 0.9% 1L over 12 hr + 0.3% KCl.

Question 368

Paediatric fluid prescription for resus?

Answer 368

20ml/kg over less 15 mins.

Question 369

Hypercalcaemia fluid requirements

Answer 369

NaCl 0.9% over 4hr.

Question 370

Hypoglycaemia management fluid?

Answer 370

50ml 20% glucose in 5 mins. STAT! It's 20% therefore 10g given as 50ml.

Question 371

IV furosemide for acute heart failure

Answer 371

Remember IV 40mg or more

Question 372

Palliative care prescribing?

Answer 372

Oral medications can be satisfactory unless there is severe nausea and vomiting, dysphagia, weakness, or coma.

Question 373

Dosing of chlordiazepoxide?

Answer 373

Calculated based on level of alcohol dependence.

Question 374

Advice with chlordiazepoxide?

Answer 374

Side effects are similar to other benzodiazepines Pregnancy - risk of neonatal withdrawal symptoms. breastfeeding - benzos are present in milk to ideally not to breastfeed while prescribed chlrodiazepoxide. Hepatic impairment - dose reduced Renal impairment - dose reduced Skilled tasks - drowsiness may persist the next day and affect performance of skilled tasks.

Question 375

What to do if warfarin is missed?

Answer 375

Appropriate to take dose later in the day. - oxycodone is metabolised by the liver to inactive metabolites. Therefore it is good in the context of those with renal impairment. Discuss bleeding risk, and patient to report any abnormal bleeding, and unusual headaches Seek urgent medical attention if you're taking warfarin and you have a fall or accident, experience a significant blow to your head, are unable to stop any bleeding, have signs of bleeding, such as bruising Skin rashes and hair loss are also common side effects

Question 376

Missed dose in warfarin?

Answer 376

- If evening doses is missed, take on the same day if remembered before midnight on the same day - If midnight has passed, leave that dose and take your normal dose the next day at the usual time

Question 377

Monitoring in Warfarin?

Answer 377

INR determined daily or on alternate days in early days, then at longer intervals (depending on response), then up to every 12 weeks. Change in clinical condition, e.g liver disease, renal disease, intercurrent illness, or drug administration, necessitates more frequent testing INR only indicates short-term control

Question 378

Assessing impact of lunchtime dose of insulin?

Answer 378

Pre-evening meal capillary blood glucose would be the most likely time point to detect hypoglycaemia.

Question 379

Anticoagulation in pregnancy?

Answer 379

LMWH - used because they do not cross the placenta. Monitor anti-Factor Xa. Dosed according to renal function. Other anticoagulants are not recommended/contraindicated in pregnancy (apixaban, dabigatran edoxaban, rivaroxaban).

Question 380

DMARDs in pregnancy?

Answer 380

``` Methotrexate Penicillamine Hydroxychloroqune Azathioprine Ciclosporin Leflunomide ```

Question 381

Should not dual anticoagulate patients on apixaban!

Answer 381

No to apixaban and enoxaparin.

Question 382

Management of Addisonian crisis?

Answer 382

Hydrocortisone is initial management. 100-500mg IM or IV.

Question 383

Pregnancy antibiotics of UTI?

Answer 383

Nitrofurantoin - suitable in first and second trimesters - should be avoided at term. Penicillin suitable but second line. Sulphonamides - avoid during pregnancy Trimethoprim - Avoid in first trimester. Avoid throughout

Question 384

Treatment of neuropathic pain?

Answer 384

Amitriptylline

Question 385

Dizziness and falls?

Answer 385

Amitriptylline | Ramipril hypotension

Question 386

Increased fracture risk?

Answer 386

Omeprazole | Prednisolone

Question 387

Drugs that interact with statin and increase risk of myopathies?

Answer 387

Amlodipine | Clarithromycin

Question 388

Poorly controlled hypertension?

Answer 388

Prednisolone | Naproxen (salt and water retention)

Question 389

Drugs not advised in pregnancy

Answer 389

- Methotrexate (Most DMARDs) penicillamine, hydroxychloroquine, azathioprine, ciclosporin, leflunomide, monoclonal antibodies. - Apixaban

Question 390

Which drugs should not be prescribed with apixaban?

Answer 390

Do not dual prescribe antiplatelets.

Question 391

Nausea and vomiting in pregnancy?

Answer 391

First line is Promethazine

Question 392

COPD Oxygen level

Answer 392

28% oxygen via Venturi Mask

Question 393

When converting morphine, add up total of regular and PRN.

Answer 393

Remember this

Question 394

Sick day rules for T1DM?

Answer 394

Never omit insulin Maintain adequate fluid intake Maintain regular carb intake. Consider antiemetic if nauseated Consider oral electrolyte replacement in diarrhoea If prolonged inability to keep down fluids - likely needs hospital admission Ketones testing 2-4 hrly.

Question 395

Patients on oral antidiabetic medication - not including sulphonylureas?

Answer 395

Continue with medication as normal - Encourage adequate fluid - Consider providing an oral electrolyte replacement

Question 396

Patients taking sulphonylureas?

Answer 396

- Minimum of daily self-blood glucose monitoring - Advice should be provided regarding the increased risk of hypoglycaemia. - Seek advice if blood glucose persistently elevated (e.g >17)

Question 397

Patient taking insulin?

Answer 397

Never omit insulin Emphasis on the importance of regular carb intake Minimum twice daily self-blood glucose monitoring Seek advice if blood glucose persistently elevated >17 Diabetic specialist nurse should provide individualised plan

Question 398

C diff management?

Answer 398

First line - oral metronidazole Second line - (intolerant to metro or severe/subsequent episodes) = Oral Vancomycin

Question 399

Missed NOAC dose?

Answer 399

Take missed dose if it is more than 6rh until your next dose. If it is less than 6 hrs, skip the dose.

Question 400

Warfarin information?

Answer 400

Missed dose - Take if on same day, do not double up Seek medical attention if - Pass melaena, haematemesis, haemoptysis, haematuria, PR bleeding. - Prolonged >10 mins epistaxis, bleeding gums. - Unusual headaches. - Have a fall or an accident. Rash and hair loss is common Be wary of drug interaction Be aware of leafy greens. Do not binge drink

Question 401

Increased dose of Sinemet - most likely side effect?

Answer 401

Dyskinesia - together with nausea. Also falls but less common.

Question 402

Neuroleptic Malignant Syndrome!

Answer 402

Causes by Antipsychotic drugs. - Hyperthermia, fluctuating level of consciousness, muscle rigidity, autonomic dysfunction. Management = Discontinuation of the antipsychotic drug - no proven effective treatment. - Bromocriptine and dantrolene have been used.

Question 403

Serotonin syndrome

Answer 403

Neuromuscular hyperactivity Hyperreflexia - INCREASED REFLEXES Autonomic dysfunction Altered mental state Sumitriptan likely to interact with Paroxetine to increase risk of serotonin syndrome. Manage with stopping offending medications, active cooling, possibly cyproheptadine.

Question 404

Taking long term steroids what do you need?

Answer 404

Alendronic acid

Question 405

Patient on digoxin for AF, currently admitted, what is the best way to manage her AF?

Answer 405

Starting a loading dose 250 micrograms IV.

Question 406

Digoxin toxicity?

Answer 406

Decreased cognitiion Yellow green visual halos Arrhythmias N+V

Question 407

Aspirin overdose?

Answer 407

Initial resp alkalosis, followed by severe metabolic acidosis. N+V, hypoglycaemia, hyperpyrexia, non-cardio pulmonary oedema. Use sodium bicarb when overdose level is not meeting criteria for haemodialysis

Question 408

Monitoring of a pneumonia?

Answer 408

Respiratory rate

Question 409

Monitoring of nitrates?

Answer 409

BLood pressure and pulse guide titrating IV GTN minute-to-minute.

Question 410

Management of Raised ICP?

Answer 410

Correct hypotension Elevate head Intubate - Hyperventilation to decreased PaCO2 Fluid restrict <1.5L a day. Consider mannitol Dexamethasone 8-16/24hr if malignancy

Question 411

SAH management

Answer 411

Fluid to maintain BP and cerebral perfusion. Aim for SBP > 160. Consider nimodipine.

Question 412

Management of acute glaucoma?

Answer 412

Acetazolamide 500mg IV

Question 413

GCA management?

Answer 413

Steroids state

Question 414

Exacerbation of asthma?

Answer 414

o2 Salbutamol nebs with O2 Is severe add Ipratropium Hydrocortisone IV or Prednisolone PO repeat salbutamol nebs every 15-30mins if PEFR <75%. Monitor ECG. If poor response to initial therapy - Consider single dose MgSO4 1.2-2g. If not improving - then consider ventilatory support - Aminophylline, IV salbutamol.

Question 415

Exacerbation of COPD?

Answer 415

Salbutamol 5mg/4h Ipratropium 0.5 mg/6hr Hydrocortisone and prednisolone IV Antibiotics if infection Physiotherapy for sputum expectoration. If no response - consider IV aminophylline if no response - consider NIPPV if RR >30.

Question 416

Anaphylaxis management?

Answer 416

``` Secure airway 100% O2 Adrenaline IM 0.5mg = 0.5ml of 1:1000. Chlorphenamine 10mg IV Hydrocortisone 200mg ```

Question 417

Acute pulmonary oedema?

Answer 417

Diamorphine Furosemide 40-80mg IV slowly GTN spray 2 puff Consider nitrate infusion if SBP >100.

Question 418

Pneumonia ?

Answer 418

Consider CURB

Question 419

Pulmonary Embolism management?

Answer 419

Do Wells Then Morphine LMWH If haemodynamically untable consider thrombolysis

Question 420

STEMI?

Answer 420

Aspirin 300mg Morphine 5-10mg GTN O2

Question 421

NSTEMI?

Answer 421

``` Morphine 5-10mg GTN Spray Aspirin 300mg and second antiplatelet (ticagrelol) Beta-blocker Fondaparinux 2.5mg or LMWH IV nitrate. ```

Question 422

Broad Complex Tachycardia?

Answer 422

Synchronised DC Correct Decreased K Amiodarone 300mg

Question 423

Torsades De pointes?

Answer 423

MgS04

Question 424

Narrow Complex Tachy?

Answer 424

Adenosine if vagal manoeuvres unsuccessful.

Question 425

Bradycardia/

Answer 425

Consider atropine

Question 426

Acute Upper GI bleed?

Answer 426

Give terlipressin + broad spectrum antibiotics

Question 427

DVT management?

Answer 427

Management of DVT - Enoxaparin 1.5mg/kg/24hrs or fondaparinux - Start Warfarin and continue of 3 months.

Question 428

Meningitis?

Answer 428

Cefotaxime

Question 429

Encephalitis?

Answer 429

Consider Aciclovir 10mg

Question 430

Status Epilepticus?

Answer 430

IV bolus lorazepam Then secon dose. Then IV infusion - Phenytoin.

Question 431

DKA?

Answer 431

Fluid - 500ml saline bolus if SBP <90 Fluid - DKA = 1L over 1 hr, then 1 L over 2rh, 1L over 4 hrs. Due to fluid deficit of 7L. Fixed rate - 50u Actrapid to 50ml 0.9% saline. Assess need for K replacement.

Question 432

Hypoglycaemia coma?

Answer 432

Conscious = 15-20g quick acting CHO snack. If conscious and uncooperative --> glucose gel. If unconscious --> 20-30 glucose IV 200ml-300ml of 20% dextrose. Consider glucagon.

Question 433

Myxoedema coma?

Answer 433

Give T3 5-20 micrograms IV slowly. | Give hydrocortisone

Question 434

Thyrotoxic storm?

Answer 434

Propranolol Antithyroid = Carbimazole Then Lugol's solution Then hydrocortisone

Question 435

Addisonian Crisis?

Answer 435

Hydrocortisone 100mg IV STAT | IV fluid bolus

Question 436

Phaechromocytoma?

Answer 436

Alpha blockade - Phentolamine | Then long acting alpha blocker - phenoxybenzamine.

Question 437

Hyperkalaemia?

Answer 437

10ml 10% calcium gluconate | 10 units actrapid in 50ml 20% glucose.

Question 438

Benzo poisoning?

Answer 438

Flumazenil 200mcg

Question 439

B blocker overdose?

Answer 439

Atropine up to 3 mg

Question 440

Iron overdose?

Answer 440

Desferrioxamine 15mg/kg/hr

Question 441

ORal anticoagulants?

Answer 441

Vit K If major bleed - give prothrombin

Question 442

Opiate overdose

Answer 442

Naloxone 0.4-2mg IV

Question 443

Digoxin overdose?

Answer 443

Decreased cognitiion, yellow-green visual halos Correct hypokalaemia to prevent arrhythmias. Inactivate digoxin specific antibody fragments - DigiFab

Question 444

Chlorpomazine - leading to dystonia (torticollis, retrocollis, glossopharyngeal dystonia, opisthotonus)?

Answer 444

Try procyclidine 5-10mg IM or IV | Lorazepam IV

Question 445

Salicylate poisoning?

Answer 445

Vomiting, dehydration, hyperventilation. Give activated charcoal if <1hr Blood Correct acidosis - alkalinisation of urine sodium bicarb. Consider dialysis - >700.

Question 446

Hypercalcaemia?

Answer 446

>3.5 and symptomatic Correct dehydration wit hIV 0.9% saline Use bisphosphonates to prevent bone resorption. Pamidronate

Question 447

Hyperkalaemia?

Answer 447

10ml 10% calcium gluconate IV over 2 mins 10 units Actrapid in 50ml 20% glucose Salbutamol 10-20mg via nebulisers

Question 448

Hypokalaemia?

Answer 448

Oral K+ Supplements e.g Sando K Review K+

Question 449

Neutropenic sepsis?

Answer 449

PipTaz