PSA Revision Flashcards
1
Q
Common Enzyme Inducers (↑ Enzyme Activity→ ↓ Drug Concentration)
A
PC BRAS: Phenytoin Carbamazepine Babiturates Rifampicin Alcohol (chronic excess) Sulphonylureas
2
Q
Common Enzyme Inhibitors
↓ Enzyme Activity→ ↑ Drug Concentration
A
AODEVICES: Allopurinol Omeprazole Disufiram (antibuse) Erythromycin Valproate Isoniazid Ciprofloxacin Ethanol (acute intoxication) Sulphonamides
3
Q
Drugs to stop before surgery
A
I LACK OP: Insulin Lithium Anticoagulants/antiplatelets COCP/HRT K-sparing diuretics Oral hypoglycaemics Perindopril and other ACE-Inhhibitors
4
Q
Drugs to stop if patient bleeding/suspected of bleeding/at risk of bleeding (ex haemoptysis)
A
Aspirin
LMWH/Heparin
Warfarin
5
Q
Drugs to stop in hyperkalaemia
A
ACE-I (contributes to renal failure/decrease renal excretion of K+)
6
Q
Antibiotics containing penicillin
A
Tazocin
Co-amoxiclav
7
Q
Interaction between warfarin and enzyme inhibitor (eg. erythromycin)
A
Increase warfarin’s effect –> increased PT and INR.
Consider in patient with excess anticoagulation
8
Q
Side Effects - Steroids
A
STEROIDS: Stomach ulcers Thin skin oEdema Right and Left heart failure Osteoporosis Infection (inc. Candida) Diabetes/Hyperglyceamia (!!!) Cushing's syndrome
9
Q
NSAIDs - cautions and contraindications
A
NSAID:
- No urine (renal failure)
- systolic dysfunction (heart failure)
- asthma
- indigestion
- dyscrasia (clotting abnormality)
10
Q
Side effects of antihypertensives
A
- Hypotension
- Bradycardia (beta blockers/calcium channel blockers)
- Electrolyte disturbance/hyperkalaemia (ACE-I/diuretics)
- Dry cough (ACE-I)
- Wheeze/worsening heart failure (beta blockers)
- Peripheral oedema/flushing (Calcium-channel blockers)
- Renal failure (diuretics)
11
Q
Antiemetics
A
Cyclizine 50mg 8-hourly IM/IV - causes fluid retention so avoid if cardiac problems
Metoclopramide 10mg 8-hourly IM/IV - use in heart failure/avoid in Parkinsons
12
Q
Loop Diuretics/Thiazide Diuretics
A
Cause hypokalaemia –> increase potassium extraction by the kidney
13
Q
Clozapine: Side-effect
A
Agranulocytosis causing neurtopenia (low neutrophils); patients require at least monthly monitoring blood tests.
14
Q
Causes of Microcytic Anaemia
A
Low MCV:
- Iron deficiency anaemia
- Thalassaemia
- Sideroblastic anaemia (unable to make Hb from iron - iron accumulates in mitochondria of RBC)
15
Q
Causes of Normocytic Anaemia
A
Normal MCV:
- Anaemia of chronic disease
- Acute blood loss
- Haemolytic anaemia (RBC destroyed faster than they are made)
- Renal failure (chronic) - kidneys not making enough EPO
16
Q
Causes of Macrocytic Anaemia
A
High MCV:
- B12/folate deficiency
- Excess alcohol
- Liver disease
- Hypothyroidism
- Haematological diseases beginning with ‘M’: myeloproliferative, myelodysplatic, multiple myeloma
17
Q
High/Low White Blood Cells
A
High neutrophils (neutrophilia): Bacterial infections/tissue damage - inflammation, infarction, malignancy/Steroids Low neutrophils (neutopenia): Viral infection/chemo or radiotherapy/clozapine (antipsychotic)/carbimazole (antithryoid) High lymphocytes (lymphocytosis): Viral infection/lymphoma/chronic lymphocytic leukaemia
18
Q
Causes of Hyponatraemia
A
Hypovolaemic: Fluid loss/Addison’s disease/Diuretics
Euvolaemic: SIADH/Hypothyroidism/Psychogenic polydipsia
Hypervolaemic: Heart/renal failure/liver failure/thyroid failure
19
Q
Causes of SIADH - Syndrome of inappropriate antidiurtetic hormone
A
- Small cell lung tumours
- Infection
- Abscess
- Drugs (carbamazepine/antipsychotics)
- Head Injury
20
Q
Causes of Hypokalaemia
A
DIRE:
- Drugs (loop and thiazide diuretics)
- Inadequete intake/intestinal loss
- Renal tubular acidosis
- Endocrine (Cushing’s/Conn’s)
21
Q
Causes of Hyperkalaemia
A
DREAD:
- Drugs (potassium-sparing diuretics and ACE-Inhibitors)
- Renal failure
- Endocrine (Addison’s)
- Artefact (ie. clotted sample)
- DKA - but be aware when DKA treated with insulin the K+ drops requiring hourly monitoring and replacement if required
22
Q
Acute Kidney Injury (AKI)
A
↑ urea = AKI or upper GI haemorrhage
- ↑urea (breakdown product of amino acids in Hb) + normal creatinine = upper GI haemorrhage
23
Q
Causes of AKI:
A
Prerenal: Dehydration/shock of any cause/Renal artery stenosis
Intrinsic: Ischaemia/Nephrotoxic antibiotics (gentamicin/vancomycin/tetracyclines)/Tablets (ACEI/NSAIDs)/Radiological contrast/Rhabdomyolysis/Gout (negatively birefringent crystals/Glomerulonephritis/Vasculitis/Choleterol
Postrenal: Stones/tumours/fibrosis/BPH/lymphadenopathy/aneurysm
24
Q
Liver Function Tests
A
Markers of hepatocyte injury/cholestasis:
- Bilirubin
- ALT/AST
- ALP
Markers of synthetic function:
- Albumin
- Vitamin-K dependent clotting factors (II, VII, IX, X) measured by PT/INR
25
Deranged Liver Function Causes
Prehepatic (↑Bilirubin): Haemolysis/Gilbert/Crigler-Najjar syndromes
Intrahepatic (↑Bilirubin/AST/ALT): Fatty Liver/Hepatitis/Cirrhosis/Malignancy/Wilson's disease/haemochromatosis/Heart failure - hepatic congestion
Posthepatic (↑Bilirubin/ALP): Gallstones/Drugs causing cholestasis/Primary biliary cirrhosis/Sclerosing cholangitis/Pancreatic/gastric cancer/lymph nodes
26
Adjusting Thyroxine dose
TSH <0.5: decrease dose
TSH = 0.5-5: same doese
TSH >5: increase dose
Change dose by the smallest increment offered
27
Abnormal Thyroid Function Tests
Primary hypothyroidism (↓T4 causing ↑TSH)
- Hashimoto's/drug-induced hypothyroidism
Secondary hypothyroidism (↓TSH causing ↓T4)
- Pituitary tumour/damage
Primary hyperthyroidism (↑T4 causing ↓TSH):
- Grave's/Toxic nodular goitre/drug-induced hyperthyroidism
Secondary hyperthyroidism (↑TSH causing ↑T4)
- Pituitary tumour
28
CXR Signs of Pulmonary Oedema
```
ABCDE:
Alveolar oedema
Kerley B lines
Cardiomegaly
Diversion of blood to upper lobes
Plueral effusions
```
29
Reversal of Warfarin
On Warfarin with any minor/major Bleeding (with any raised INR) = give IV Vitamin K (allows synthesis of Factors 2, 7, 9, 10)
INR>8 = give oral Vitamin K
Major bleeding = give Beriplex (prothrombin complex)
30
Neutropenic sepsis
Any case of sepsis with neutrophils <1
Tx: IV piperacillin with tazobactam and gentamicin
31
Addison's Disease
Steroid dose must be increased when patients are sick
32
Treatment of Acute Heart Failure
Signs of right-sided (raised JVP + peripheral oedema) and left-sided (bilateral creps and breathlessness) heart failure = congestive cardiac failure
Furosemide: main treatment for acute heart failure - in acute setting give IV
33
PRN dose of Morphine Sulphate
Calculated as 1/6th of total daily dose of morphine
34
Management of STEMI
1. ABC and O2 (15L) non-rebreathe mask
2. Hx, Ex, Ix
3. Aspirin 300mg oral
4. Morphine 5-10mg IV with metoclopramide 10mg IV
5. GTN spray/tablet
6. Primary PCI or thrombolysis
7. Beta-blocker (atenolol 5mg unless LVF/asthma)
8. Transfer to CCU
35
Management of NSTEMI
1. ABC and O2 (15L) non-rebreathe mask
2. Hx, Ex, Ix
3. Aspirin 300mg oral
4. Morphine 5-10mg IV with metoclopramide 10mg IV
5. GTN spray/tablet
6. Clopidogrel 300mg and LMW heparin (enoxaparin 1mg/kg BD SC)
7. Beta-blocker (atenolol 5mg unless LVF/asthma)
8. Transfer CCU
36
Management of Left ventricular failure (LVF)
1. ABC and O2 (15L) non-rebreathe mask
2. Hx, Ex, Ix
3. Sit patient up
4. Morphine 5-10mg IV with metoclopramide 10mg IV
5. GTN spray/tablet
6. Furosemide 40-80mg IV
7. If inadequate response: isosorbide dinitrate infusion +- CPAP
8. Transfer CCU
37
Management of Anaphylaxis
1. ABC and O2 (15L) for non-rebreathe mask
2. Hx, Ex, Ix
3. Remove cause ASAP
4. Adrenaline 0.5mg of 1:1000 IM
5. Chlorphenamine 10mg IV
6. Hydrocortisone 200mg IV
7. Asthma Tx if wheeze
8. Amend drug chart allergies
38
Management of Asthma **** check this one
1. ABCDE
2. Hx, Ex, Ix
3. 100% O2 non-rebreathe mask
4. Salbutamol (5mg NEB)
5. Hydrocortisone 100mg IV or prednisolone 40-50mg (if mild)
6. Ipratropium nebs
7. Theophylline (only if life threatening)
39
Community-acquired pneumonia severity
```
CURB 65
Confusion
Urea >7.5mmol/L
Respiratory Rate >30/min
Blood Pressure (systolic) <90mmHg
Age 65years +
```
2+: Hospital Treatment with oral/IV antibiotics
40
DKA: Diagnostic Criteria
1. Diabetic (hyperglycaemia: BM>30 mmol/L)
2. Keto (check urine/blood levels)
3. Acidosis (also look for ↑K+)
41
Hyperglycaemic HONK coma: Diagnostic Criteria
1. Hyperglycaemia (>35mmol/L)
2. Hyperosmolar (osmolality >340mmol/L)
3. No ketones in urine/blood
42
Hypertension Management
Step 1:
Under 55 years: ACEI/ARB
Over 55 years/Afro-Caribbean: Calcium-channel blocker (CCB)
Step 2: ACEI/ARB + CCB
Step 3: ACEI/ARB + CCB + Thiazide-diuretic
Step 4: Resistant - expert advice
43
Atrial Fibrillation: Stroke Prevention
Stroke Prevention: Use CHADS2-VASC to determine require anticoagulation
Score 0 = Aspirin 75mg OD
Score 1 = Aspiring/Warfarin (target INR 2.5)
Score 2 = Warfarin (INR 2.5)
44
Atrial Fibrillation: Rate/Rhythm Control
Rhythm control - young/symptomatic AF/caused by precipitant
Tx: cardioversion - electrical or pharmacological (amiodarone)
Rate control: anyone with HR>90bpm
Tx: Beta-blocker (propranolol) or calcium-channel blocker (diltiazem) then add Digoxin (or use if beta-blockers/CCB contraindicated)
45
Management of Asthma (Chronic)
1. Inhaled short-acting B2 agonist (salbutamol)
2. Add inhaled steroid
3. Add LABA (salmeterol)/Increase steroid if required
4. Luekotriene receptor antagonist
5. Refer to specialist
46
Management of Type 1/2 Diabetes
1. Patient education (diet/exercise)
2. CV risk factor modification - aspirin 75mg if CV risk factors (or age 50+ with T2DM)
- simvastatin if CV risk (or age 40+ with T2DM)
3. Check albumin-creatinine ratio - indicator of diabetic neuropathy/cardio disease - AR>3 then ACEI
4. Blood glucose lowering therapy
47
Epilepsy Treatment
```
Generalised tonic-clonic: Na+ Valproate (TERATOGENIC!)
Absence: Na+ valproate/ethoxsuximide
Myoclonic: Na+ valproate
Tonic: Na+ valproate
Focal: carbamazepine/lamotrigine (RASH!)
```
48
Laxatives
Stool softener: Docusate sodium (good for faecal impaction)
Bulking agents: Isphagula husk (contraindicated in faecal impaction)
Stimulants: Senna
Osmotic: Lactulose
49
Anti-muscarinic side effects
- Dry mouth
- Dilated pupils - difficulty accomodating to light/possible double vision
- Dry skin
- Constipation
- Bradycardia
50
Drugs that cause neutropenia
Carbimazole
| Carbamazepine
51
Drugs with Parkinsonian S/E
Metoclopramide and haloperidol - dopamine agonists (make parkinson's symps worse!)
Domperiodone: dopamine antagonist safe to use as anti-emetic in Parkinsonian patients
52
ACEI in Pregnancy
Teratogenic esp in 1st trimester - advice to convert to labetalol pre-conception
53
Methotrexate
- 1-2 weekly blood tests required to monitor FBC
- Should be taken once/week
- Higher risk of infection
- Folate antagonists (trimethoprim/co-trimoxazole) should NEVER be used as increases effect
- Folic acid given everyday (except methotrexate day) to limit toxicity to bone marrow
54
Warfarin
-significant risk of bleeding
| -
55
Anti-platelets prior to surgery
Stop anti-platelets 7 days before surgery. Ie. aspirin 75mg/clopidogrel
56
Breakthrough Pain - Fentanyl Patch
Patients on at least 25microgram patch can use nasal fentanyl - 50 micrograms per nostril (repeat once after 10 mins as required)
57
INR (Day before surgery)
If INR>1.5 on day before surgery - phytomenadione (Vitamin K) 1-5mg PO given
58
Changes in Creatinine when starting ACEI
Small rise (<20%) in creatinine to be expected when starting an ACEI - doesn't require investigation or prescription change
59
Adverse Effects Ciclosporin
Nephrotoxicity and hypertension - check baseline renal function before begin treatment and monitor every 2 weeks until results stable
60
Statins
Expect to see a >40% reduction in non-HDL cholesterol after 3 months of treatment
Stop statin if myopathy severe and creatine kinase is 5x normal --> reintroduce at lower dose
Give at Night!
61
Vancomycin
Reduced clearance in patients with renal dysfuncuon - check renal func with serum creatinine.
S/E: ototoxicty and nephrotoxicity
62
Renally eliminated
Check renal function - serum creatinine
63
Fluid Requirements (Electrolyte Abnormalities)
1L 0.9% NaCl = 154 mmol Na/Cl
For 80kg man daily requirements:
Na/Cl: 80mmol
K+: 80mmol
- Can use 5% dextrose to maintain hydration if blood glucose okay
2000-2400mL per day for 80kg man
