Miscellaneous

Question 1

Spinal cord syndromes?

Answer 1

Question 2

Multiple endocrine neoplasia?

Answer 2

Question 3

MEN venn diagram?

Answer 3

Question 4

Nephrotic/nephritic syndromes?

Answer 4

Question 5

Triad of nephrotic syndrome? Consequence?

Answer 5

1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema

Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis. Loss of thyroxine-binding globulin lowers the total, but not free, thyroxine levels.

Question 6

Stomas?

Answer 6

• In emergency when the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon.
• End colostomy is often safer and can be reversed later.
• Resection of the sigmoid colon + formation of end colostomy = Hartmans procedure.
• Whilst left sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned.

Question 7

Target INRs?

Answer 7

Question 8

Starting on warfarin?

Answer 8

1. Decide on target INR and duration of therapy
2. Consider need for bridging LMWH until INR in target range
3. Decide on loading regime
   
   • Standard = 10 mg
   • Sensitive - >65 years, ↑baseline INR, cardiac failure, liver disease, nutritional deficiencies, body weight <50kg, etc = 5mg
4. Measure INR daily
5. Prescribe warfarin based upon INR measurements

Question 9

What to do when INR is too high and no bleeding?

Answer 9

Question 10

What to do when INR is too high and minor bleeding? (epistaxis, haematoma)

Answer 10

Question 11

What to do if INR too high and major bleeding?

(intracranial, GI bleeding, intraocular, pericardial bleeds, compartment syndrome, shock)

Answer 11

1. Stop warfarin
2. Re-start when INR <5.0
3. IV vitamin K 5-10mg
4. Prothrombin complex concentrate (PCC)

Question 12

What is prothrombin complex concentrate?

Answer 12

AKA: PCC, octaplex

• Produced by fractionation of pooled plasma from non-UK donors
• Contains factors II, VII, IX and X
• IV infusion
• Re-check clotting 20 minutes after injection

3ml/min via syringe driver (10 ml/min if life threatening)

Question 13

How to monior unfractionated heparin?

Answer 13

APTT

Question 14

Name some combination insulins?

Answer 14

Humalog Mix50 and Humalog Mix25

Long-acting mixed with a bit of rapid-acting

Question 15

How to prescribe regular insulin?

Answer 15

• Name of insulin & brand name
• Type of device
• Exact time & units to be given
• Then simply sign!

Question 16

Example of common insulin regime?

Answer 16

Some will be on different doses at different times

• Humalog Mix50 14 units OM
• Humalog Mix50 10 units lunch & tea

So write it up on the SAME prescription

• Humulog Mix50 12 units morning & night
• Actrapid 6 units with every meal

So write TWO SEPARATE prescriptions

Question 17

Why is LMWH better than unfractionated?

Answer 17

Lower risk of HIT (heparin induced thrombocytopenia) and longer half life (mainly given OD)

Question 18

Example of someone starting on warfarin? (pic)

Answer 18

Question 19

Coverage and indications of gentamycin?

Answer 19

• Aminoglycoside
• Broad spec (anaerobes, streptococci, pneumococci)
• Endocarditis, biliary sepsis, pyelonephritis, CNS infections

Question 20

Initial doses of gent?

Answer 20

Usually 5-7mg/kg (1-2mg/kg in CKD)

Question 21

How to prescribe gentamicin?

Answer 21

1. Height and weight(actual and IBW)
2. Prescribe initial dose (7 mg/kg)
3. Work out when gentamicin and creatinine levels need to be taken (6-14 hours after start of first dose)
4. Take gent & creat levels (every dose)
5. Once have results use the Hartford normogram to work out whether to:
   
   • Stop gentamicin if too high
   • To work out the dosing interval
6. Prescribe doses until next gentamicin level required

Levels should be checked every 3rd day/dose, check cr daily.

Document this on gent administration record - on drug chart, in dose write ‘as per chart’.

Question 22

Coverage and indications of vancomycin?

Answer 22

Glycopeptide (bactericidal)

Only aerobic & anaerobic gram-positive bacteria

IV usually, oral ONLY if local GI effect needed

Resistant staph infections, C. diff

Question 23

Adverse effects of vancomycin?

Answer 23

• Red man syndrome
  
  • Flushing, fever, histamine-related anaphylactoid reaction
• Nephrotoxicity, ototoxicity
• Neutropenia, thrombocytopenia

Question 24

Prescribing vanc?

Answer 24

1. Indication & duration
2. Target trough levels:
   
   • 10-20 mg/L = normal trough
   • 15-20 mg/L = if treating for less susceptible strains or MRSA/more complication infections
3. Baseline characteristics:
   
   • BMI = weight/height²
   • Creatinine clearance = CrCl (NOT eGFR). Calculated using Cockcroft-gault equation
4. Loading dose is based on weight (1-2g)
5. Maintenance dose based on CrCl and find out time of first vancomycin trough level (total no of doses includes loading dose)
   
   • 1-1.5g every 12 hours if normal renal function
   • Take trough level before 4th dose
6. Prescribe initial maintenance dose until dose after trough level due
7. Check vancomycin trough level
8. Decide on subsequent dosing level and monitoring

Question 25

Interpreting vanc trough levels?

Answer 25

Question 26

Bristol stool chart?

Answer 26

Question 27

C.diff toxin and blood GDH level results? ## Footnote (Glutamate dehydrogenase)

Answer 27

Question 28

How to reverse NOACs?

Answer 28

* No ‘antidote’ * Can give tranexamic acid, mefanamic acid, terlipressin, vitamin K * Discuss with Haematology EARLY for advice

Question 29

Prescription requirements for controlled drugs?

Answer 29

* In indelible ink * The name and address of the patient * The dose * The form of the preparation * The strength of the preparation * The total volume/dose in words and figures * Signed and dated by the prescriber, be dated, specifying the prescriber's address

Question 30

Example of NAC prescription?

Answer 30

Question 31

VTE risk factors?

Answer 31

Question 32

Contraindications to VTE prophylaxis?

Answer 32

* Concurrent use of anticoagulants * Acute stroke * Thrombocytopenia (platelets \<75x109/l) * Bleeding disorders * Acute liver failure * Untreated inherited bleeding disorders (e.g. haemophilia) * Active bleeding

Question 33

Patterns of transferase rise?

Answer 33

* ALT \> AST in chronic disease * AST \> ALT in cirrhosis

Question 34

Answer 34

Posterior MI

Question 35

Answer 35

WPW

Question 36

Answer 36

Question 37

Answer 37

Question 38

Management of delirium?

Answer 38

Determine Cause (A-E) - collateral history Look at meds Bloods/Imaging Validated screening tool (CAM tool)

Question 39

3 distinct clinical entities in delirium?

Answer 39

Hyperactive: Agitated Mixed = Hypoactive - Hyperactive Hypoactive = hypoalert, withdrawn, confused