Random Flashcards
In addition to the primary hosptial team, who else should be involved in a patient with severe cellulitis?
Ensure chiropody involvement
If someone has been taking duloxetine for 2 months, what is important that we do?
Review efficacy - according to NICE guidance all drugs used for neuropathic pain should be reviewed after 2 months and if ineffective a different one trialed.
Why might diabetic patients with cellulitis need to be managed differently?
A diabetic patient is likely to have anaerobic bacteria involved.
What must be stated when starting antibiotics?
Indication Dose Frequency Length of the course - VERY IMPORTANT Oral/IV? If IV when are we going to review to switch Monitoring
What should be monitored in a patient with an infection?
WCC, Temperature, visual signs of infection reducing, ESR, CRP, HR, BP
What should we be concerned with when using the antibiotic clindamycin?
With systemic use: Clindamycin has been associated with antibiotic-associated colitis, which may be fatal. Although antibiotic-associated colitis can occur with most antibacterials, it occurs more frequently with clindamycin. Patients should therefore discontinue treatment immediately if diarrhoea develops.
What is the target blood glucose level in patients with diabetes during surgery or acute illness?
Aim for a target plasma glucose level of 5-8 mmol/l
If a patients type 1 diabetes is poorly controlled, before making adjustments to their regime what should we check?
Check for adherence and technique, including asking where patient injects. Adults with type 1 diabetes should rotate their injection site to avoid lipodystrophy which cna decrease the amount of insulin absorbed
How often should injection site conditions be checked/reviewed?
Check injection site condition at least annually and if new problems with blood glucose occur.
How do we make up a VRIII for acutely unwell patients?
50 units actrarapid in 50ml 0.9% saline infused at a rate according to BGs. With concurrent infusion of glucose +/- potassium in suitable IV fluid.
What target HbA1c is advised to minimise the risk of long-term vascular conditions?
<48
What is the recommended basal bolus regimen? (NICE)
Rapid acting analogue e.g. Novorapid TDS before meals (not human insulin)
AND
BD determir basal bolus = long acting insulin give twice daily
What type 1 diabetics might benefit from metformin?
Consider adding metformin to insulin therapy if an adult with type 1 diabetes and a BMI of 25kg/m2 (23kg/m if south asian) or above wants to improve their blood glucose control while minimising insulin dose
what is the HTN target in a diabetic with organ damage?
130/80
A raised ACR is indicative of what?
Target organ damage
why is it important for diabetics to achieve their BP target?
Important to prevent further complications as a result of hypertension e.g. CV disease, nephropathy, eye disease
What are the macrovascular complications associated with diabetes?
MI, Stroke, peripheral vascular disease
Do we need to carry out QRISK2 assessment in patients with type 1 diabetes?
NO - if they have high cholesterol then can start statin
How should we monitor complications associated with diabetes? Who is involved?
Optician, podiatrist, GP, diabetic nurse check ups, renal function
What is the baseline monitoring for LMWH?
APTT, INR, platelets, LFTs, renal function (CrCl in elderly)
What are the two ways dalteparin can be dosed in patients in obese patients/patients >83kg?
Either give 18,000 units OR this might not be appropraite if patient is 120kgetc…. so could give 100units/kg BD
What is the duration of LWMH for a PE/DVT treatment?
Continue until diagnosis confirmed and OAC decided - how long we continue will depend on the requirements of the specific OAC
Who is at risk of hyperkalemia when administering LMWH? Why does it occur?
Inhibition of aldoesterone secretion by heparins can result in hyperkalemia. Patients with diabetes, CKD, acidosis or raised K levels are more susceptible. Risk increases with the duration of the therapy
What is the continued monitoring required with LMWH?
Signs of brusing and bleeding
Platelets if >4 days
No monitoring of factor Xa unless special circumstance
Briefly outline the options of continuing management of PE/DVT
Continue use of LMWH
Warfarin
DOAC
How long must LMWH heparin be administered for PE/DVT treatment before dabigatran can be started?
5 days
Why might apixaban/rivaroxaban be preferred in the ongoing management of PE/DVT vs dabigtran?
LMWH must be administered for 5 days before you can start dabigatran whereas apixaban and rivaroxaban can be started as soon as diagnosis confirmed.
Why might dabigatran not be a good drug in elderly patients?
CI in renal impairment Large tablet - difficult to swallow Dexterity required to remove from packing Cannot go in MDA boxes Reduced efficacy at extremes of weight
What is an important counselling point regarding how rivaroxaban should be taken?
Must be taken with FOOD
If a patient misses their dose of OD rivaroxaban what should they do?
Patients can take it within 12 hours of when it was due - after this time, they should omit the dose and take the next one as scheduled
If patients miss their dose of BD dabigatran or apixaban what should they do?
Patients can take it within 6 hours - after this time should omit dose and take next one as scheduled
What is the loading dose of warfarin?
10mg/10mg/5mg unless elderly, liver impairment, bleeding risk when it would be 5mg/5mg
How long should we bridge LWMH and warfarin for following a PE/DVT?
Continue the LMWH for 5 days AND until the INR is >2 for 2 days
what is a common risk factor(s) for VTE in elderly patients?
Immobility
Dehydration - elderly pt often dont drink enough
If a patient has poor inhaler technique with a pMDI what could we do?
Either educate or switch to a DPI
If a patient has had good asthma control for 3 months what should we consideR?
Stepping down - reduce ICS dose by 25-50% every 3 weeks.
PPIs are associated with hyponatremia, which has a lower risk?
Lansoprazole has lower risk than omeprazole
If an elderly patient is taking codiene long term what would be want to consider?
Constipation and drowsiness = falls
An elderly patient using ICS for asthma is at risk of what?
osteoporosis
At what K+ level should we stop an ACEi?
> 6mmol/L
If a patient is taking warfarin and amiodarone, why would we be concerned?
Interaction - patient requires more frequent INR monitoring. Consider switching to DOAC
What baseline monitoring is required with antipsychotics
BP, HbA1c, FBC, LFTs, U&Es, lipids, BMI, TSH, prolactin, ECG for clozapine
Is propanolol a selective or non-selective BB?
Non-selective.
Propanolol should be avoided in who?
Diabetics, COPD and asthma
what is important counselling advice with carbimazole
Warn patient to tell doctor immediatley if sore throat, mouth ulcers, bruising, fever, malaise develops.
How can prednisolone alter blood glucose levels?
Prednisolone can raise BG levels
Patients with HF are at risk of their condition worsening if they take corticosteroids. How should this be managed if they must have the steroid? i.e. COPD exacerbation
Use lowest dose possible for the shortest amount of time
When should we measure serum digoxin levels?
Only measure if toxicity is suspected e.g. N&V, visual disturbances
What could be differentitial diagnoses for symptoms presenting as a TIA? what should we do?
hypoglycemia - rule out by measuring BG levels
How should VTE prophylaxis be managed in stroke patients?
Do NOT give LMWH or AES
Hydration, mobility and mechanical foot pumps
When shoud we reduced the apixaban dose in patients taking for stroke prevention?
reduce dose to 2.5mg BD if two of the following apply: weight <60kg, patient is over 80, or is serum creatine is >133.
If a patient only has AF and no other co-morbities, what might be the best option in terms of BB?
Atenolol and OD
Why is digoxin a STOPP drug?
risk of toxicity as narrow therapeutic range and therefore falls
Why might bendroflumethizide be a concern in elderly patients?
Risk of hyponatremia and falls/confusion
What is postural hypotension defined as?
drop in systolic BP of 20mmHg and diastolic BP of 10mmHg
When given LMWH to pregnant patients what should be consider?
Doses should be given BD because of PK changes
Ensure the vial doesn’t contain benzyol alcohol
Dose based on early pregnancy weight
Can we use LMWH is a patient has an epidural in situ?
NO - high bleed risk
How should pain be managed in a STEMI?
S/L GTN spray and morphine iv 5-10MG (reduced dose in elderly patients)
What drugs should be given acuteley in patients with STEMI?
Pain relief
Oxygen if hypoxic
Antiplatelet - aspirin 300mg (chewed/dispersed) and clopidogrel 300mg
Fondaparinux 2.5mg s/c up to 8 days or until discharge unless PCI or angiography planned in the next 24 hours
What is GRACE score used to predict?
6 month mortality following NSTEMI or UA
How should an acute NSTEMI/UA be managed
Aspirin - 300mg loading, 75mg thereafter
Clopidogrel 600mg
Consider glycoprotien IIb/IIIa inhibitors if GRACE score >3%
Fondaparinux unless angiography in next 24 hours
When is CABG preferred over PCI?
CABG is the treatment of choice in patients with severe multi-vessel disease or with co-morbidities such as diabetes
How soon after an ACS event should ACEi be offered? And how should the ACEi be titrated?
Offer as soon as haemodynamically stable. Titrate quickly e.g. every 12-24 hours
When do we offer conservative management (i.e. pharmacological only) after a NSTEMI/UA?
If GRACE score <3%
When should BB be offered after ACS event?
Offer as soon as possible - IV BB has been associated with better outcomes (atenolol avaliable for IV), then switch to oral
When would an aldosterone antagonist be indicated after ACS?
For patients who have had an acute MI and signs of heart failure. Eplerone is licensed for this.
What is the first line treatment for angina?
GTN spray and either a BB or CCB
PLUS secondary prevention
Depression is fairly common following an MI - what are the risks of this and how can we manage it?
Depression is associated with decreased medical adherence and poorer outcomes. SSRIs are prefferred (TCAS cardiotoxic in overdose) but caution with citalopram and escitalopram as cause QT prolongation.
How should osteoarthiritis be managed in elderly patients?
Paracetamol and topical NSAIDS
Not oral NSAIDs
codeine - consider falls and side effects
Seretide contains what?
Salmeterol and fluticasone
How should fentanyl be prescribed?
BY brand
When managing a 90 year old patient what is important in all decisions?
Consider patients QoL vs long term risk reductions
What medication should be start a newly diagnosed T2 diabetic taking warfarin for AF and with renal impairment (eGFR = 38)
Metformin could be started and require close monitoring - should stop in less than 35, so would probably avoid.
Sulphonyureas interact with warfarin so require close monitoring - could start OR switch patient do a DOAC.
Pioglitazone is CI in what patients?
patients with HF
Is donepazil ok in patients with uncontrolled COPD?
Can worsen the COPD - need to control it first and then consider use with caution.
Can we use BB in an asthmatic with HF?
Yes - this is the only time we would see it. Use an cardioselective BB with caution
When might a TCA and SSRi be prescribed together?
TCA for neuropathic pain and the SSRI for depressio n
What is an iatrogenic problem?
A problem caused by a decision made by the HCP
Why might a diabetic not tolerate a BP target of 130/80
Can cause problems with dizziness and make it difficult for them to function
What HbA1c is needed in diabetics before surgery?
<69
Assuming eGFR >60, how should metformin be taken on the day of surgery?
Take as normal if OD or BD dosing
omit lunch is TDS
How should the total daily units be split in a basal bolus regimen? and where should the insulin be injected
2/3 for the bolus and 1/3 for the basal.
inject bolus into arm/abdomen
basal into thigh
Outline sick day rules for diabetics
don't stop tkaing insulin test glucose every 2 hours test urines for ketones increased fluid intake to 3L eat as normally as possible
Can we stop duloxetine abruptly?
No - taper dose
Can we stop pregabalin aburuply?
No - taper dose
Why might gabapentin not be the drug of choice in diabetics with neuropathic pain?
Can alter blood glucose levels = increased monitoring
If a patient is taken amiodarone or verapamil for rhythm control in AF, what OAC might be preferred?
Apixaban - doesnt interact.
If a patient has AF due to hyperthyroidism, do we still anticoagulate?
Yes - if chadsvasc outweighs hasbled. Should review need after successful treatment of the hyperthyroidism and stop OAC once AF has been documented to not be present for 3 months.
How should warfarin be started in AF?
Use a slower loading regime e.g. 1mg/2mg on the first few days
what is the target INR in recurrent VTE?
3.5
What is teh target INR for mechanical mitral values?
3.5
What is the target INR in VTE prevention?
2.5-3
what is the target INR in AF?
2.5-3
QRISK CV risk assessment should not be used in who?
pre-existing CVD, T1DM, or if GFR <60
Why is propylthiouracil not first line in hyperthyroidism?
Small risk of severe liver injury
How often should TSH and free T4 be measured in patients taking carbimazole?
every 4-6 weeks and then when on maintenance dose every 3 months
Patients with cardiac disease require lower doses of levyothyroxine, why?
higher doses can cause exacerbation
How should hypothyroidism induced constipation be managed?
1st line diet
2nd line bulk forming e.g. laxido
once controlled assess need
Ranitidine is not a ‘risk free’ drug in elderly patients, why might we be concerned?
1 point on ACB scale
Why might we not put alendronic acid in a dossete box?
risk of it being taken like any other tablet
What drug should be used to manage nausea in parkinsons diease?
Domperidone
What drug should be used for BPH in dementia? what are the issues with the other options
Use finasteride
Tamulosin is an alpha blocker
Which antidepressant has the lowest propensity for interactions?
Sertraline
what is type 1 respiratory failure?
Oxygen <8kPa and normal/low CO2
What is type 2 respiratory failure?
Oxygen <8kPa and CO2 >6.5
When should dabigatran be stopped before surgery?
If CrCl >79 - 48 hrs major/36 hours minor
If CrCl 50-79 - 72 hours major/ 48 hours minor
If CrCl 30-49 - 5 days before major and 72 hours minor
When should rivaroxaban be stopped before surgery?
24 hours before
When should apixaban be stopped before surgery?
24 hours minor
48 hours major
If a patient requires emergeny surgery within teh next 24 hours and they are on warfarin, what should we offer them?
Vitamine K
An pre-op assessment in your AF patient takng warfarin says they have a CHADS2 score of 2, what should you do?
No LMWH is required, stop wafarin5 days before
An pre-op assessment in your AF patient says they have a CHADS2 score of 3, what should you do
Stop warfarin 5 days before Give therapeutic dose of LMWH 2 days after stopping warfarin
Should clopidogrel be stopped before surgery?
Yes - stop 7 days before and switch to aspirin where possible
Your patient has been told to stop taking the bisoprolol before surgery, is this correct?
NO CONTINUE ALL BB - risk of tachycardia and arrythmias
Which of the following should be stopped/continued before surgery and when: Aspirin Clopidogrel Ramipril Bisoprolol Atorvastatin
Additional Q: what might this patients PMH be? and how would this influence your decisions
Aspirin continue (assuming patient has had a previous MI and this is secondary prevention) Clopidogrel - stop 7 days before BUT if MI was recent, should look at delaying surgery because of the risks associate with stopping Ramipil - usually continue, monitor patient for AKI and hypotension Bisoprol - continue Atorvasatin - continue
A person is adrenally suppressed if what?
they take 10mg/day of pred in the last 3 months
