Random Flashcards
1
Q
Which troponins are specific to cardiac muscle?
A
Troponin T and Troponin I
2
Q
A troponin level should be taken when? What level is considered significant?
A
Levels should be taken on arrival, then at 30 minutes and 1 hour. A normal level is <30
If above 100 = strongly indicative of myocardial damage
3
Q
Why is creatinine kinase not measured routinely in patients with suspected MI?
A
Not selective for myocardial damage as also found in skeletal muscle. Exercise can cause levels to raise
4
Q
Outline initial management of ACS
A
Aspirin 300mg STAT Morphine IV for pain Metoclopramide PO betabocker Tight glucose control
5
Q
Duration of DAPT in patient with bare metal stent?
A
1 month only
if patient has had an MI event, then DAPT automatically defaults to 1 year
6
Q
Duration of DAPT in patient with drug eluting stent?
A
12 months
7
Q
How to beta blockers work?
A
B1/B2 adrenoreceptor antagonists
Reduces the sympathetic stimulation on the heart and cardiovascular system
Reducing myocardial contractility and oxygen demand, this reduces the stress on the myocardium and prevents further ischemic damage
8
Q
Name the cardioselective beta blockers
A
Atenolol, bisoprolol or metoprolol
9
Q
Why might eplenerone be preferred in men (instead of spironolactone)?
A
Spironolactone can cause breast tenderness and swelling. Doesn’t occur with eplenerone
10
Q
When are aldosterone antagonists recommended post MI?
A
Recommended by NICE for patients with evidence of heart failure (EF<40%) POST mi
Start within 3-14 days of event
Eplenerone is a licensed for this indication
11
Q
What is paroxysmal AF?
A
Episodes lasting longer than 30 seconds but less than 7 days, they are self-terminating and recurrent
12
Q
What is persistent AF?
A
AF episodes lasting longer than 7 days require pharmacological or electrical cardioversion
13
Q
What is permanent AF?
A
AF that failure to terminate using cardioversion, or relapses within 24 hours
14
Q
Causes of AF
A
Hypertension, coronary artery disease and myocardial infarction
Congestive heart failure, rheumatic valvular disease
Acute infection, electrolyte depletion, cancer, pulmonary embolism, diabetes
15
Q
HASBLED
A
Hypertension Abnormal liver/renal function Stroke Bleeding Labile INR Elderly - over 65 years Drugs (antiplatelet agents or NSAIDs) Harmful alcohol consumption
16
Q
Beta blocker adverse effects
A
Bradycardia, bronchospasm, cold extremities, conduction disorders, dizziness, fatigue, sleep disturbances
17
Q
Which beta blocker is less likely to cause sleep disturbances?
A
Water soluble beta blocker - atenolol
18
Q
Diltiazem side effects?
A
Dizziness, GI disorders, fatigue, flushing, headaches, ankle swelling
19
Q
Verapamil side effects?
A
Constipation, nausea, vomiting, dizziness, fatigue, flushing, headaches, ankle swelling
20
Q
Digoxin therapeutic range
A
0.7ng/ml -2ng/ml
21
Q
When should digoxin levels be taken?
A
At least 6 hours post dose
Ideally 8-12 hours afterwards
22
Q
Amiodarone baseline monitoring
A
Thyroid function tests LFTs Potassium Chest x-ray ECG
23
Q
Amiodarone adverse effects
A
Pulmonary toxicity inc. pneumonitis and fibrosis
Thyroid dysfunction (hypo or hyperthyroidism)
Visual disorders (corneal microdeposits)
Photosensitivity reactions
24
Q
Amiodarone + colestyramine interaction
A
Colestyramine reduces amiodarone levels buy 50%
25
Amiodarone + digoxin interaction
Amiodarone may increase plasma levels of digoxin
26
Amiodarone + simvastatin interaction
Increases simvastatin levels, max recommended dose is 20mg
27
Amiodarone + warfarin interaction
Amiodarone increases the anticoagulant effects of warfarin. Monitor INR
28
NYHA Class I definition
No limitation on physical activity. Ordinary physical activity does not cause undue fatigue, breathlessness or palpitations
29
NYHA Class II definition
Slight limitation of physical activity. Comfortable at rest
30
NYHA Class III definition
Marked limitation of physical activity, less than ordinary physical activity results in undue breathlessness etc
31
NYHA Class IV definition
Unable to carry out any physical activity without discomfort, symptoms at rest
32
Outline initial heart failure management
```
Loop diuretics
Start ACEi and BB
Consider anti-platelet
Prescribe statin
Refer to exercise based rehab programme
Offer annual flu vaccine and once only pneumococcal vaccine
```
33
Patient heart failure advice
```
Monitor weight at home
Max salt consumption 6g/day avoid LoSalt products
Fluid restriction to 1.5-2L/day
Sick day rules regarding ACEi and ARBs
Smoking cessation
Alcohol consumption
Physical activity
```
34
Which beta blockers are licensed in heart failure?
Bisoprolol, carvediolol and nebivolol
35
When should beta blockers be started in heart failure?
Should only be started once a person is stable - without fluid overload or hypotension
36
Outline potassium monitoring after starting ACEi/ARB
Monitor baseline potassium - do not initiate treatment if K+ >5mmol/L
Recheck in 1-2 weeks - stop if K+ is above 5.5mmol/L
37
Stage 1 hypertension
clinic bp 140/90mmHg
| and ABPM 135/85mmHg
38
Stage 2 hypertension
clinic BP 160/100mmHg or ABPM 150/95mmHg
39
Stage 3 hypertension
180>mmHg or diastolic BP >120mmHg
40
Step 1 antihypertensive treatment
< 55 years - ACEi or an ARB
| or >55 years or black african/caribbean offer a CCB
41
Step 2 antihypertensive treatment
ACEi/ARB +CCB
42
Step 3 antihypertensive treatment
ACEi + CCB + thiazide like diuretic
43
Step 4 antihypertensive treatment
ACEi + CCB + thiazide-like diuretic
If K+ <4.5 consider low-dose spironolactone
If K+ >4.5 consider an alpha or beta blocker
44
Management of angina attack
Stop what they are doing and rest
Use GTN spray/tablets
Take a second dose after 5 minutes if pain has not eased
Call 999 if pain has not eased 5 minutes after the second dose
45
First line treatment for angina
Beta blocker or a rate limiting calcium channel blockers
aspirin 75mg OD
Statin
Treat hypertension
46
When should asthma treatment be stepped up from a SABA?
Patient has used an inhaled SABA three times a week or more, have asthma symptoms 3 times a week or more, are woken up at night by asthma symptoms once or more
47
Patient on SABA PRN + low dose ICS. What is the next step of treatment?
Consider LTRA
| Offer LABA in combination with ICS
48
How to decrease asthma maintenance therapy?
Consider decreasing therapy if asthma has been controlled for at least 3 months
Decrease dose by 25-50% each time
49
Prednisolone dose for acute asthma exacerbation
40-50mg for 5 days
50
Baseline monitoring before starting theophylline therapy
Urea and electrolytes - particularly K+
| Liver function
51
Target theophylline concentration
10-20mg/L
52
Examples of factors that increase theophylline half life
Fever, heart failure, elderly and hepatic impairment
53
COPD diagnosis
Symptoms and spirometry (post bronchodilator FEV1/FVC less than 0.7)
54
What is cor pulmonale?
Right sided heart failure secondary to lung disease - caused by pulmonary hypertension as a consequence of hypopoxia
55
When is a VRIII indicated peri-operatively?
If starvation period >one meal and usually on insulin
OR
If usually non-insulin managed only use VRIII if BMs>12 for >2 hours and pt is NBM
56
How should a VRIII be prescribed?
Humuan soluble insulin 50 units in 50mL
Always continue long acting insulin
Run with glucose 5%
Run with potassium in fluids
57
Outline warfarin management peri-operatively
Stop 5 days pre-op
| If bridging required (MVR, recurrent DVT/PE, high risk AF) then switch to treatment dose LMWH on day 3
58
Average daily fluid requirements
25-30ml/kg/day
| For obese patients adjust to IBW
59
How often should children have their BMs checked?
5 times a day
60
How often should type 1 diabetics monitor their BMs?
At least 4 times a day, monitor more frequently during periods of illness, stress etc
61
How often should type 2 diabetes monitor their BMs?
Not routinely required - only necessary if patient on insulin or there is evidence of hypoglycemia
62
When should ketones be tested in diabetes?
Urine ketone testing is not recommended as it is imprecise and cumbersome
Ketones are not routinely checked but are considered part of sick day rules -
Ketones should be checked when BG levels >14mmol/L
63
Management of suspected TIA
Give aspirin 300mg immediately and continue until diagnosis established
64
When should anticoagulants be started following an AF-related stroke?
Patients should receive aspirin 300mg for 2 weeks before being considered for anticoagulant treatment
Patients already receiving anticoagulation are at significant risk of haemorrhagic transformation and should have their anticoagulant treatment stopped for 7 days
65
Should you treat hypertension in acute phase of stroke?
Treatment of hypertension in the acute phase can result in reduced cerebral perfusion and should therefore only be instituted in the event of a hypertensive emergency
66
Secondary prevention following ischeamic stroke or TIA
Long term clopidogrel
if clopidogrel C/I prescribe M/R dipyridamole in combination with aspirin
High intensity statin 48 hours after stroke onset
67
Blood pressure target following the acute phase of ischaemic stroke?
Target BP <130/80mmHg
68
How does aspirin work as an antiplatelet?
Irreversibly inhibits cyclo-oxygenase and blocks the production of thromboxane
69
How does clopidogrel and ticagrelor work?
Thienopyridines
They inhibit the binding of adenosine into erythrocytes, platelets and endothelial cells, resulting in an increased extracellular concentration of adenosine, which is a potent inhibitor of platelet activation and aggregation
70
What is parkinsons disease?
PD is a chronic, progressive neurodegenerative condition resulting from the loss of the dopamine containing cells of the substantia niagra
71
Why should ergot derived dopamine agonists not be used first line?
Risk of cardiac fibrosis
72
Dopamine receptor side effects
Excessive sleepiness, hallucinations and impulse control disorders are more likely to occur with dopamine-receptor agonists then with levodopa
Risk of postural hypotension - monitor blood pressure
73
What type of drug is selegiline?
Monoamine oxidase B inhibitor
74
How should entacapone be prescribed?
Prevents the breakdown of levodopa by inhibiting catechol-O-methyltransferase should be prescribed in adjunct to levodopa for patients with 'end-of-dose' motor fluctuations
75
First line treatment for status epilepticus?
Benzodiazepine- IV lorazepam
| or buccal midazolam or rectal diazepam solution
76
2nd line treatment for status epilepticus?
Phenytoin or phenobarbitol
77
Which antipsychotics are most commonly associated with extrapyramidal symptoms?
Fluphenazine, prochlorperazine, haloperidol
78
Which antipsychotics might be preferred in a patient not wanting side effects from hyperprolactinaemia (sexual dysfunction, breast enlargement)
Aripiprazole (partial dopamine agonist)
79
Which antipsychotics are most commonly associated with sexual dysfunction? Why does sexual dysfunction occur?
Risperidone
Haloperidol
Occurs due to reduced dopamine transmission and hyperprolactinaemia
80
Which antipsychotics commonly cause weight gain?
Clozapine
| Olanzapine
81
Which class of antipsychotics might be preferred to treat negative symptoms of schizophrenia?
Second generation (atypical) antipsychotics
82
Antipsychotics with a reduced tendency to prolong QT interval
```
Aripiprazole
Amisulphride
Clozapine
Fluphenazine
Olanzapine
```
83
How is clozapine dose titrated?
12.5mg 1-2 times a day on day 1, 25-50mg day 2, then increased in steps of 25-50mg daily. Max dose 900mg
If doses are missed for more than 48 hours then will need to be retitrated
84
Clozapine monitoring
Weekly FBC for 18 weeks
Then at least every 2 weeks for 1 year.
After 1 year - if stable can reduce to 4 weekly monitoring
Blood lipids and weight should be measured at baseline, at 3 months and then yearly
Fasting blood glucose baseline, at 4-6 months and then yearly
85
Treatment of variceal haemorrhage
Terlipressin IV
| Prophylactic beta blocker such as propranolol
86
What causes ascites?
```
Portal hypertension (results in an increased circulating volume)
Decreased metabolism of aldosterone encourages sodium and water retention
Decreases albumin synthesis reduces the oncotic pressure which results in fluid accumulating in tissues
```
87
Management of ascites
Sodium restriction
| Spironolactone - aim for weight loss of 0.5kg/day (or 1kg/day if peripheral oedema is present)
88
How is spontaneous bacterial peritonitis (SPB) diagnosed and treated?
Ascitic neutrophil count >250 cells/mm3
Rx antibitoics - ceftriaxone 2g IB BD or ciprofloxacin
May need albumin infusion
89
What causes hepatorenal syndrome?
portal hypertension leads to peripheral vasodilation
This drop in blood pressure activates the renin-angiotensin pathway
Results in renal vasoconstriction and AKI
90
Management of coagulopathy
IV vitamin K 10mg for up to 3 days
Do not give PO as absorption is impaired in cholestasis
IM not recommended due to risk of haematoma
91
Azathiopurine and allopurinol interaction
Allopurinol increases levels - reduce azathiopurine dose to one-quarter of usual dose
92
MRSA treatment options
Resistant to flucloxacillin
Glycopeptides e.g. vancomycin
Clindamycin
Linezolid in combination with other antibacterials
93
Signs and symptoms of hyperthyroidism
TSH low
T3/4 high
Increased irritability, sweating, tremor, lethargy, tachycardia, palpitations, arrythmia
94
Signs and symptoms of hypothyroidism
Low T3/4
TSH high
Lethargy, pale skin, slow speech, constipation, bradycardia, cold intolerance, weight gain
95
How is urea produced?
Break down to amino acids
96
What factors can increase urea levels?
Impaired renal function, dehydration, GI bleed, increased protein breakdown (post-op, trauma, infection), high protein diet, starvation-> increased catabolism
97
What factors can decrease urea levels?
Malnutrition, liver disease, pregnancy
98
Why does dehydration increase urea levels?
Urea is an osmotic diuretic, and so is reabsorbed in dehydrated states.
Therefore can be used to interpret someones fluid status - if urea raised but creatinine isn't then pt is likely dehydrated
99
Management of hyperkalemia
1) IV calcium gluconate 10% - stabilises myocardial membrane, has no effect on K+ levels. Do not give if Ca>3mmol/L or if pt has digoxin toxicity
2) Insulin-glucose infusion - 10 units of actrapid in 50mL of glucose 5%. Shifts potassium into cells
3) Salbutamol 10mg via nebuliser. Shifts potassium into cells
100
Why is sodium chloride the preferred diluent for IV potassium replacement?
If replace with glucose 5% then this stimulates insulin production and further reduces potassium levels
101
When might high concentration potassium be appropriate? i.e. 40mmol in 500mL
Patients with fluid restriction - should be given via central vein. Not to be used for rapid K+ replacement
102
Signs of hypernatremia
extreme thirst, headache, confusion, nausea and vomiting, lethargy, seizures, nystagmus, loss of consciouness
103
Causes of hypernatremia
Most common cause if water depletion - either inadequate intake or excessive loss
Diabetes insipidus
Low fluid intake commonly in elderly/dementia
104
Causes of hyponatremia <130mmol/l
renal losses such as diuretics, hypoadrenalism
diarrhoea, vomiting, burns
SIADH
Oedematous states - cirrhosis, congestive heart failure
105
Signs and symptoms of low Mg (<0.75mmol/L)
Cramps, tetany, paraesthesia (pins and needles), convulsions, arrythmias and ECG changes
106
Causes of high mg (>1.5mmol/L)
Renal failure or Mg administration
107
Signs of high Mg
K+ level >1.5mmol/L
| Nausea, flushing, headache, lethargy, drowsiness, hypotension, respiratory failure
108
Management of raised calcium levels
Rehydrate with NaCl 0.9%
| Zolendronic acid 4mg over 15 minutes
109
Limitations of the cockcroft-gault equation
Does not account of differences in race
Does not account for muscle mass
Calculations are based on steady state - less useful in acute renal failure
Inaccurate at extremes of body weight - may need to use adjusted body weight
110
What causes acidosis in CKD? How is it treated?
In CKD the kidneys are less able to excrete H+ and re-absorb HCO3-
Rx PO sodium, bicarbonate 1g TDS
Give IV in acute setting
Caution as increased Na levels will cause fluid retention.
111
Prothrombin time reference range
10-14 seconds
112
Describe the different types of enteral feeding tubes
1. Nasogastric (NG) - Inserted through the nose into the stomach. For short term use only, up to 4 weeks. Long fine bored tubes which can block easily
2. Percutaneous endoscopic gastrostomy (PEG) - inserted directly through the abdominal wall. For long term feeding, shorter with a wider bore
3. Percutaneous endoscopy jejunostomy (PEJ)
113
Standard questions to ask when asked about administration of medications
Why can't the medications be given orally
Why type of enteral tube does the patient have?
How long will the patient be NBM?
What the doses of the drugs and their indications?
Does the patient have IV access?
Is there any reason why alternative routes would be inappropriate e.g. ongoing diarrhoea and PR
114
Define type A ADR reaction
A = augmented
Result from an exaggeration of a drugs normal physiological actions when given at the usual therapeutic dose and are normally dose dependent
Examples: opioids and respiratory depression, warfarin and bleeding, dry mouth and TCAs
115
Define type B ADR reaction
B = bizarre
Novel responses that are not expected from the known pharmacological actions of the drug
These are less common, so may only be discovered for the first time after a drug has already been made available for general use
116
Define type C ADR
C = continuing
| Reactions which persist for a relatively long time e.g. osteonecrosis of the jaw and bisphosphonates
117
Define type D ADR
D = delayed
become apparent sometime after the use of a medicines
The timing of these make them more difficult to detect
e.g. leucopenia can occur up to six weeks after a dose of lomustine
118
Define type E reactions
E = end of use
| Reactions associated with the withdrawal of a medicine
119
What adverse drug reactions should be reported via the yellow card scheme?
New medications under the black triangle scheme (usually for 5 years)
All reactions that a serious/medically significant/result in harm
Medications taken during pregnancy
Medications used in children
120
What factors should be considered when predicting the compatibility of two injectable medications?
1. pH - is the pH similar? Drugs with very different pH values are less likely to be compatible
2. Are chemically similar drugs compatible?
3. Do the injections have a similar formation? aqeuous vs lipid
4. Are any of the injections new products? may have limited data
5. What concentrations are being used?
6. What diluents are being used?
121
What are the four different types of RRT?
1. Haemodialysis
2. Haemofiltration
3. Haemodiaflitration
4. Peritoneal dialysis
122
Outline haemodialysis
Dialyser is composed of thousands of hollow synthetic fibres which acts as a semi-permeable membrane
Water, waste products and excessive electrolytes move from the blood into the dialysis solution via DIFFUSION
Essential nutrients from the dialysis solution enter the blood via diffusion
123
Outline haemofiltration
Similar to HD. The blood is pumper through a dialyser, however a negative pressure is applied to the dialysate, causing solutes to move across a pressure gradient, as opposed to diffusion
More aggressive than HD
124
Outline peritoneal dialysis
In PD the inside lining of the peritoneum acts as a natural filter
A catheter is placed in the abdomen surgically
Sterile dialysate is then put into the peritoneum
waste diffuses into the dialyslate
125
What are the principles of homeopathy?
1. Like cures like - a patients symptoms are treated with a substance that could cause the same symptoms, but only a tiny dose is used
2. The more dilute a preparation is, the more potent it is
126
Chloroquine is contraindicated in which patients?
Patients with epilepsy
| Patients taking amiodarone (increased risk of ventricular arrhythmias)
127
Mefloquine is contraindicated in which patients?
People with current or previous hx of depression
Generalised anxiety disorder, psychosis
Epilepsy
128
Mefloquine monitoring
More LFTs and eye assessments for visual disorders
129
Can patients be administered more than one vaccine at a time?
Yellow fever and MMR - a four week minimum interval period should be observed between administration. Should not be administered on the same day as can lead to a sub-optimal antibody response
Varicella and MMR - can either be administered on the same day, or requires a 4 week interval
No other restrictions
130
Which guide outlines travel vaccine advice?
The green book
131
The presence of post void residual volume greater than 30mL indicates what?
Obstruction and post-renal AKI
132
Why can sepsis result in AKI?
Leads to diversion of the blood to the peripheries away from essential organs
133
Linezolid monitoring requirements
Weekly FBC
134
Daptomycin monitoring requirements
Monitor creatine phosphokinase before treatment and then at least weekly
Monitor more frequently in patients at higher risk of developing myopathy e.g. renal impairment, taking statins
Monitor renal function
135
Chloramphenicol monitoring requirements
Monitor plasma concentrations in elderly and children <4 years
FBC before and during treatment
136
What is the difference between gram positive and negative bacteria?
Gram +ive bacteria have thick peptidoglycan layer, non outer membrane
Gram -ive outer membrane is present
137
When would you expect to use the IV route for antimicrobial therapy?
For patients who are strictly NBM
Patients with a non-functional GI tract or malabsorption
For life threatening infections or severe sepsis
For patients with serious deep seated infections
138
Amoxicillin might sometimes be attributed to the development of a rash in patients with what specific infection?
Glandular fever (Epistein-barr virus)
139
List the sepsis 6
1. Give fluids
2. Give oxygen
3. Give broad spectrum iv abx
4. Take blood
5. Check lactate
6. Urine output measurement
140
What is defined daily dose? or ddd?
The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. Gives a rough estimate of consumption
141
Can nitrofurantoin be given in pregnancy?
Yes with caution - avoid in third trimester (specifically after 37 weeks) due to risk of neonatal haemolysis
142
Can nitrofurantoin be given for pyelonephritis?
Not recommended as does not reach therapeutic concentrations in the upper urinary tract
143
How should tazocin be administered?
Over at least 30 minute infusion
| bolus injection is not appropriate
144
What is the only treatment that slows progression of copd?
Smoking cessation
145
Oxygen target saturations in COPD?
88-92%
146
Dose and duration of prednisolone to treat COPD exacerbation
30mg 7-14 days
147
What is roflumilast? When is it indicated?
Phosphodiesterase inhibitor with anti-inflammatory properties
May be used in severe COPD - pt with post bronchodilator FEV <0.5 and more than 2 exacerbations in last 12 months despite triple inhaler therapy
148
Suggested first line antidepressant in adolescents
Fluoxetine (as licensed)
149
Suggested first line antidepressant in hepatic disease
Paroxetine (short half life)
150
Suggested first line antidepressant in cardiac disease
Sertrlaine
Avoid citalopram and escitalopram
Avoid TCAs
151
Examples of drugs implicated in serotonin syndrome
SSRIs, SNRIs, sumatriptan, MAOIs, linezolid, tramadol, St Johns Wort, amphetamines
152
Signs and symptoms of serotonin syndrome
Changes in mental state - feeling confused, agitated and/or restless
Physical symptoms - sweating, diarrhoea fever, tachycardia
Seizures and fits
153
Which medication might be a suitable option for a patient with depression complaining of sexual dysfunction?
Mirtazipine
154
What foods should be avoided with phenelzine?
Phenelzine = MAOI
| Avoid matured foods e.g. cheese, wine, marmite
155
Which hypnotic might be useful for someone with insomnia who has to work the next morning?
Zolpidem - has shortest half life
156
After how many missed days should lamotrigine therapy be retitrated?
Retitrate is more than 3 days missed
157
Prochlorperazine MOA?
Dopamine D2 antagonist
158
Max rate of IV potassium chloride when administered peripherally?
10mmol/hr
159
Max concentration of IV potassium chloride that can be administered via peripheral line?
The concentration of potassium for intravenous administration via a peripheral line should not exceed 40mmol/L, as higher strengths can cause phlebitis and pain.
160
Dalteparin mechanism of action
Binds to antithrombin III
| Antithrombin III usually activates factor Xa and thrombin, therefore LMWH causes inactivation of Xa
161
Apixaban mechanism of action
Direct Xa inhibitor
This prevents conversion of prothrombin to thrombin
Prevents conversion of fibrinogen to fibrin
162
Candesartan mechanism of action
Angiotensin II receptor blocker
Stops binding to Angiotensin II to AT1 receptor - this prevents vasoconstriction and inhibits the release of aldosterone --> therefore reduces sodium retention
163
Aspirin mechanism of action
Inhibits COX-1 enzyme
| COX-1 usually converts arachidonic acid to prostagradlin H2 and thromboxane A2
164
NICE Asthma guidance - adults
```
Step 1 - SABA
Step 2 - SABA + low dose ICS
Step 3 - consider LTRA
Step 4 - ICS/LABA +/- LTRA
Step 5 - Switch to MART regimen
Step 6 - increase to moderate dose ICS
```
165
NICE asthma guidance in children 5-16 years
Step 1. SABA
Step 2. Low dose ICS
Step 3. ICS + LTRA
Step 4. ICS/LABA + LTRA
166
Advise nurse on how to administer IV phenytoin
Dilute in 50-100mL of saline (do not mix with glucose as precipitates)
Max conc in 10mg/ml
Administer slowly through large vien - max rate is 50mg/min, using an inline filter of 0.22-0.50microns
Monitor ECG and blood pressure
Check infusion site of complications and monitor for phlebitis
Flush line before and after administration
167
ACE inhibitor and renal function advice
If serum creatinine levels rises by more than 20%
or eGFR decreases by 15% remeasure in 2 weeks
If serum creatinine increases by 30-50% OR to over 200 or eGFR decreases by 30% then this should prompt dose reduction/stopping
If serum creatinine increases by more than 100% or to greater than 310umol stop ACEi
168
Lifestyle advice for GORD
```
Weight loss
Avoid trigger foods - spicy/fatty foods
Eating smaller meals, eat last meal 3-4 hours before bed
Stop smoking
Reduce alcohol consumption
Sleep with head of bed raised - put bricks under bed
Assess for stress and anxiety
Review medications that might cause
Prescribe PPI
```
169
What factors should be considered when reviewing if a medication is safe to give while breastfeeding?
1. Maternal systemic exposure i.e. PO vancomycin is not absorbed systemically
2. Lipophillicity - lipophillic drugs can cross the epilethium
3. Neonatal clearance - renal/liver is not fully matured, medications with short t 1/2 is preffered
4. Neonatal toxicity - avoid known toxic drugs
5. Acid-base balance - breast milk is slightly acidic, this ionises weak bases, makes them water soluble so unable to pass back into blood stream and accumulates in the breast milk
6. Protein binding - highly protein bound drugs are less likely to pass intro breastmilk
7. Consider whether drugs inhibit lactation
170
Severe COPD is defined as?
FEV1% predicted <30%
171
Most common causative organisms of cellulitis
Staph. aurea
| Strep pyogenes
172
How do NSAIDs work?
Inhibit COX-1 and COX-2 enzymes to reduce prostaglandins
COX-1 inhibitors e.g. low dose aspirin, are associated with highest risk of bleeding
COX-2 inhibitors e.g. celecoxib results in cardiac side effects
173
How does naloxone work?
It is a semi synthetic opioid antagonist that acts competitively at opioid receptors. It has a very high affinity for opioid receptor sites so displaces agonist and partial agonists.
174
How does buprenorphine work?
Partial opioid agonist
Acting at mu opioid receptor
Also a kappa receptor weak antagonist
175
How does tramadol work/?
Mu opioid receptor agonist
| weak inhibition of the uptake of serotonin and noradrenaline
176
How does moxifloxacin work?
Inhibits topoisomerase II (DNA gyrase) and topoisomerase IV. Enzymes are essential for DNA replication, repair
177
How does cefalexin work? What type of antibiotic is it?
First generation cephalosporin
Bind to penicillin binding proteins to prevent cell wall formation
(Gram positive bacteria have thick cell wall. Less effective against gram negative because they have an outer membrane surrounding the cell wall)
178
How does simvastatin work?
Inhibits HMG-COA reductase in the liver
Results in reduced production of mevalonate - rate limiting step in cholesterol biosynthesis. Leads to reduced cholesterol
Decreased hepatic cholesterol concentrations leads to upregulation of LDL receptors which increases uptake of LDL
179
How does spironolactone work?
Competitively inhibits aldosterone dependent sodium=potassium exchange in the distal convoluted tubule to promote Na and water excretion and K+ retention.
180
How does warfarin work?
Warfarin is a vitamin K antagonist
It inhibits the production of vitamin K by vitamin K epoxide reductase
The reduced form of vitamin K is usually involved in the carboxylation of coagulation factors 2, 7, 9 and 10
Uncarboxylated factors are inactive
181
How does fluphenazine work?
First generation antipsychotic
| Blocks dopamine D1 and D2 in the mesolimbic pathway
182
How does metformin work?
1. Decreases hepatic glucose production - gluconeogenesis
2. Decreased intestinal absorption of glucose
3. Increased insulin sensitivity by increasing peripheral glucose uptake
