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Clinical - Rosie > Random > Flashcards

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1
Q

In addition to the primary hosptial team, who else should be involved in a patient with severe cellulitis?

A

Ensure chiropody involvement

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2
Q

If someone has been taking duloxetine for 2 months, what is important that we do?

A

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.

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3
Q

Why might diabetic patients with cellulitis need to be managed differently?

A

A diabetic patient is likely to have anaerobic bacteria involved.

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4
Q

What must be stated when starting antibiotics?

A 
Indication
Dose 
Frequency 
Length of the course - VERY IMPORTANT 
Oral/IV? If IV when are we going to review to switch
Monitoring
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5
Q

What should be monitored in a patient with an infection?

A

WCC, Temperature, visual signs of infection reducing, ESR, CRP, HR, BP

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6
Q

What should we be concerned with when using the antibiotic clindamycin?

A

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.

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7
Q

What is the target blood glucose level in patients with diabetes during surgery or acute illness?

A

Aim for a target plasma glucose level of 5-8 mmol/l

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8
Q

If a patients type 1 diabetes is poorly controlled, before making adjustments to their regime what should we check?

A

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

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9
Q

How often should injection site conditions be checked/reviewed?

A

Check injection site condition at least annually and if new problems with blood glucose occur.

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10
Q

How do we make up a VRIII for acutely unwell patients?

A

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.

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11
Q

What target HbA1c is advised to minimise the risk of long-term vascular conditions?

A

<48

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12
Q

What is the recommended basal bolus regimen? (NICE)

A

Rapid acting analogue e.g. Novorapid TDS before meals (not human insulin)
AND
BD determir basal bolus = long acting insulin give twice daily

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13
Q

What type 1 diabetics might benefit from metformin?

A

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

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14
Q

what is the HTN target in a diabetic with organ damage?

A

130/80

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15
Q

A raised ACR is indicative of what?

A

Target organ damage

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16
Q

why is it important for diabetics to achieve their BP target?

A

Important to prevent further complications as a result of hypertension e.g. CV disease, nephropathy, eye disease

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17
Q

What are the macrovascular complications associated with diabetes?

A

MI, Stroke, peripheral vascular disease

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18
Q

Do we need to carry out QRISK2 assessment in patients with type 1 diabetes?

A

NO - if they have high cholesterol then can start statin

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19
Q

How should we monitor complications associated with diabetes? Who is involved?

A

Optician, podiatrist, GP, diabetic nurse check ups, renal function

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20
Q

What is the baseline monitoring for LMWH?

A

APTT, INR, platelets, LFTs, renal function (CrCl in elderly)

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21
Q

What are the two ways dalteparin can be dosed in patients in obese patients/patients >83kg?

A

Either give 18,000 units OR this might not be appropraite if patient is 120kgetc…. so could give 100units/kg BD

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22
Q

What is the duration of LWMH for a PE/DVT treatment?

A

Continue until diagnosis confirmed and OAC decided - how long we continue will depend on the requirements of the specific OAC

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23
Q

Who is at risk of hyperkalemia when administering LMWH? Why does it occur?

A

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

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24
Q

What is the continued monitoring required with LMWH?

A

Signs of brusing and bleeding
Platelets if >4 days
No monitoring of factor Xa unless special circumstance

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25
Q

Briefly outline the options of continuing management of PE/DVT

A

Continue use of LMWH
Warfarin
DOAC

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26
Q

How long must LMWH heparin be administered for PE/DVT treatment before dabigatran can be started?

A

5 days

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27
Q

Why might apixaban/rivaroxaban be preferred in the ongoing management of PE/DVT vs dabigtran?

A

LMWH must be administered for 5 days before you can start dabigatran whereas apixaban and rivaroxaban can be started as soon as diagnosis confirmed.

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28
Q

Why might dabigatran not be a good drug in elderly patients?

A 
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
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29
Q

What is an important counselling point regarding how rivaroxaban should be taken?

A

Must be taken with FOOD

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30
Q

If a patient misses their dose of OD rivaroxaban what should they do?

A

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

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31
Q

If patients miss their dose of BD dabigatran or apixaban what should they do?

A

Patients can take it within 6 hours - after this time should omit dose and take next one as scheduled

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32
Q

What is the loading dose of warfarin?

A

10mg/10mg/5mg unless elderly, liver impairment, bleeding risk when it would be 5mg/5mg

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33
Q

How long should we bridge LWMH and warfarin for following a PE/DVT?

A

Continue the LMWH for 5 days AND until the INR is >2 for 2 days

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34
Q

what is a common risk factor(s) for VTE in elderly patients?

A

Immobility

Dehydration - elderly pt often dont drink enough

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35
Q

If a patient has poor inhaler technique with a pMDI what could we do?

A

Either educate or switch to a DPI

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36
Q

If a patient has had good asthma control for 3 months what should we consideR?

A

Stepping down - reduce ICS dose by 25-50% every 3 weeks.

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37
Q

PPIs are associated with hyponatremia, which has a lower risk?

A

Lansoprazole has lower risk than omeprazole

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38
Q

If an elderly patient is taking codiene long term what would be want to consider?

A

Constipation and drowsiness = falls

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39
Q

An elderly patient using ICS for asthma is at risk of what?

A

osteoporosis

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40
Q

At what K+ level should we stop an ACEi?

A

> 6mmol/L

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41
Q

If a patient is taking warfarin and amiodarone, why would we be concerned?

A

Interaction - patient requires more frequent INR monitoring. Consider switching to DOAC

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42
Q

What baseline monitoring is required with antipsychotics

A

BP, HbA1c, FBC, LFTs, U&Es, lipids, BMI, TSH, prolactin, ECG for clozapine

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43
Q

Is propanolol a selective or non-selective BB?

A

Non-selective.

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44
Q

Propanolol should be avoided in who?

A

Diabetics, COPD and asthma

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45
Q

what is important counselling advice with carbimazole

A

Warn patient to tell doctor immediatley if sore throat, mouth ulcers, bruising, fever, malaise develops.

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46
Q

How can prednisolone alter blood glucose levels?

A

Prednisolone can raise BG levels

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47
Q

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

A

Use lowest dose possible for the shortest amount of time

48
Q

When should we measure serum digoxin levels?

A

Only measure if toxicity is suspected e.g. N&V, visual disturbances

49
Q

What could be differentitial diagnoses for symptoms presenting as a TIA? what should we do?

A

hypoglycemia - rule out by measuring BG levels

50
Q

How should VTE prophylaxis be managed in stroke patients?

A

Do NOT give LMWH or AES

Hydration, mobility and mechanical foot pumps

51
Q

When shoud we reduced the apixaban dose in patients taking for stroke prevention?

A

reduce dose to 2.5mg BD if two of the following apply: weight <60kg, patient is over 80, or is serum creatine is >133.

52
Q

If a patient only has AF and no other co-morbities, what might be the best option in terms of BB?

A

Atenolol and OD

53
Q

Why is digoxin a STOPP drug?

A

risk of toxicity as narrow therapeutic range and therefore falls

54
Q

Why might bendroflumethizide be a concern in elderly patients?

A

Risk of hyponatremia and falls/confusion

55
Q

What is postural hypotension defined as?

A

drop in systolic BP of 20mmHg and diastolic BP of 10mmHg

56
Q

When given LMWH to pregnant patients what should be consider?

A

Doses should be given BD because of PK changes
Ensure the vial doesn’t contain benzyol alcohol
Dose based on early pregnancy weight

57
Q

Can we use LMWH is a patient has an epidural in situ?

A

NO - high bleed risk

58
Q

How should pain be managed in a STEMI?

A

S/L GTN spray and morphine iv 5-10MG (reduced dose in elderly patients)

59
Q

What drugs should be given acuteley in patients with STEMI?

A

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

60
Q

What is GRACE score used to predict?

A

6 month mortality following NSTEMI or UA

61
Q

How should an acute NSTEMI/UA be managed

A

Aspirin - 300mg loading, 75mg thereafter
Clopidogrel 600mg
Consider glycoprotien IIb/IIIa inhibitors if GRACE score >3%
Fondaparinux unless angiography in next 24 hours

62
Q

When is CABG preferred over PCI?

A

CABG is the treatment of choice in patients with severe multi-vessel disease or with co-morbidities such as diabetes

63
Q

How soon after an ACS event should ACEi be offered? And how should the ACEi be titrated?

A

Offer as soon as haemodynamically stable. Titrate quickly e.g. every 12-24 hours

64
Q

When do we offer conservative management (i.e. pharmacological only) after a NSTEMI/UA?

A

If GRACE score <3%

65
Q

When should BB be offered after ACS event?

A

Offer as soon as possible - IV BB has been associated with better outcomes (atenolol avaliable for IV), then switch to oral

66
Q

When would an aldosterone antagonist be indicated after ACS?

A

For patients who have had an acute MI and signs of heart failure. Eplerone is licensed for this.

67
Q

What is the first line treatment for angina?

A

GTN spray and either a BB or CCB

PLUS secondary prevention

68
Q

Depression is fairly common following an MI - what are the risks of this and how can we manage it?

A

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.

69
Q

How should osteoarthiritis be managed in elderly patients?

A

Paracetamol and topical NSAIDS
Not oral NSAIDs
codeine - consider falls and side effects

70
Q

Seretide contains what?

A

Salmeterol and fluticasone

71
Q

How should fentanyl be prescribed?

A

BY brand

72
Q

When managing a 90 year old patient what is important in all decisions?

A

Consider patients QoL vs long term risk reductions

73
Q

What medication should be start a newly diagnosed T2 diabetic taking warfarin for AF and with renal impairment (eGFR = 38)

A

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.

74
Q

Pioglitazone is CI in what patients?

A

patients with HF

75
Q

Is donepazil ok in patients with uncontrolled COPD?

A

Can worsen the COPD - need to control it first and then consider use with caution.

76
Q

Can we use BB in an asthmatic with HF?

A

Yes - this is the only time we would see it. Use an cardioselective BB with caution

77
Q

When might a TCA and SSRi be prescribed together?

A

TCA for neuropathic pain and the SSRI for depressio n

78
Q

What is an iatrogenic problem?

A

A problem caused by a decision made by the HCP

79
Q

Why might a diabetic not tolerate a BP target of 130/80

A

Can cause problems with dizziness and make it difficult for them to function

80
Q

What HbA1c is needed in diabetics before surgery?

A

<69

81
Q

Assuming eGFR >60, how should metformin be taken on the day of surgery?

A

Take as normal if OD or BD dosing

omit lunch is TDS

82
Q

How should the total daily units be split in a basal bolus regimen? and where should the insulin be injected

A

2/3 for the bolus and 1/3 for the basal.
inject bolus into arm/abdomen
basal into thigh

83
Q

Outline sick day rules for diabetics

A 
don't stop tkaing insulin
test glucose every 2 hours
test urines for ketones
increased fluid intake to 3L
eat as normally as possible
84
Q

Can we stop duloxetine abruptly?

A

No - taper dose

85
Q

Can we stop pregabalin aburuply?

A

No - taper dose

86
Q

Why might gabapentin not be the drug of choice in diabetics with neuropathic pain?

A

Can alter blood glucose levels = increased monitoring

87
Q

If a patient is taken amiodarone or verapamil for rhythm control in AF, what OAC might be preferred?

A

Apixaban - doesnt interact.

88
Q

If a patient has AF due to hyperthyroidism, do we still anticoagulate?

A

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.

89
Q

How should warfarin be started in AF?

A

Use a slower loading regime e.g. 1mg/2mg on the first few days

90
Q

what is the target INR in recurrent VTE?

A

3.5

91
Q

What is teh target INR for mechanical mitral values?

A

3.5

92
Q

What is the target INR in VTE prevention?

A

2.5-3

93
Q

what is the target INR in AF?

A

2.5-3

94
Q

QRISK CV risk assessment should not be used in who?

A

pre-existing CVD, T1DM, or if GFR <60

95
Q

Why is propylthiouracil not first line in hyperthyroidism?

A

Small risk of severe liver injury

96
Q

How often should TSH and free T4 be measured in patients taking carbimazole?

A

every 4-6 weeks and then when on maintenance dose every 3 months

97
Q

Patients with cardiac disease require lower doses of levyothyroxine, why?

A

higher doses can cause exacerbation

98
Q

How should hypothyroidism induced constipation be managed?

A

1st line diet
2nd line bulk forming e.g. laxido
once controlled assess need

99
Q

Ranitidine is not a ‘risk free’ drug in elderly patients, why might we be concerned?

A

1 point on ACB scale

100
Q

Why might we not put alendronic acid in a dossete box?

A

risk of it being taken like any other tablet

101
Q

What drug should be used to manage nausea in parkinsons diease?

A

Domperidone

102
Q

What drug should be used for BPH in dementia? what are the issues with the other options

A

Use finasteride

Tamulosin is an alpha blocker

103
Q

Which antidepressant has the lowest propensity for interactions?

A

Sertraline

104
Q

what is type 1 respiratory failure?

A

Oxygen <8kPa and normal/low CO2

105
Q

What is type 2 respiratory failure?

A

Oxygen <8kPa and CO2 >6.5

106
Q

When should dabigatran be stopped before surgery?

A

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

107
Q

When should rivaroxaban be stopped before surgery?

A

24 hours before

108
Q

When should apixaban be stopped before surgery?

A

24 hours minor

48 hours major

109
Q

If a patient requires emergeny surgery within teh next 24 hours and they are on warfarin, what should we offer them?

A

Vitamine K

110
Q

An pre-op assessment in your AF patient takng warfarin says they have a CHADS2 score of 2, what should you do?

A

No LMWH is required, stop wafarin5 days before

111
Q

An pre-op assessment in your AF patient says they have a CHADS2 score of 3, what should you do

A

Stop warfarin 5 days before Give therapeutic dose of LMWH 2 days after stopping warfarin

112
Q

Should clopidogrel be stopped before surgery?

A

Yes - stop 7 days before and switch to aspirin where possible

113
Q

Your patient has been told to stop taking the bisoprolol before surgery, is this correct?

A

NO CONTINUE ALL BB - risk of tachycardia and arrythmias

114
Q 
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

A 
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
115
Q

A person is adrenally suppressed if what?

A

they take 10mg/day of pred in the last 3 months

Clinical - Rosie (16 decks)

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