Mocks from book

Question 1

Regular medicaitons and surgery, what should happen with the following?

• antiplatelets, anticoagulants and COCP
• metformin
• insulin
• BBs & CCBs
• Lithium

Answer 1

○ Antiplatelets, anticoagulants and the COCP should be stopped without alternatives sought
- LMWH should be stopped 24 hrs before surgery, and not started until 48hrs after if surgery carries high risk of bleeding,
- Warfarin = 5 days before
- COCP at least 4 wks before
- antiplatelets? 5 days
○ Metformin should be stopped the day of surgery (due to risk of lactic acidosis in the event of renal compromise during surgery)
§ Consider ‘sliding scale’
○ Insulin should also be stopped & converted to sliding scale
○ Don’t stop drugs like BBs and CCBs before surgery : can cause intraoperative complications
Lithium should be omited the day before surgery

Question 2

What is tamoxifen and when might it be used in men?

Answer 2

SERM (selective oestrogen receptor modulator)

in breast & prostate cancer

Question 3

What is the dose of alendronic acid?

Answer 3

OD 10mg

70mg for Rx of post-menopausal osteoporosis once weekly

Question 4

what is the dose of aspirin

Answer 4

• standard prophylactic = 75mg

- 300mg is treatment dose (for stroke and ACS) which is rarely given beyond 2 weeks

Question 5

what is Qlaira?

Answer 5

A COCP

dienogest with estradiol

Question 6

explain lithium toxicity and renal failure

Answer 6

Mild lithium toxicity = tremor. Moderate = lethargy. Severe = seizure, coma, arrhythmias & renal failure

• Lithium excretion is significantly reduced by ACE-I, diuretics and NSAIDs & Loop diuretics are the safest if they must be given
• (rather than the toxicity being caused by renal failure, RF is a consequence of the toxicity)
• So stop these drugs that caused the toxicity

If severe is suspected, dialysis is required

Question 7

is hashimotos thyroiditis hyper or hypo?

how should levothyroxin dose change?

whats one thing that doesn’t speed up/increase in hyperthyroid?

Answer 7

HYPO

in 25-50 microgram increments,. in absence of toxicity, should be the smallest increment possible

Question 8

If someones sodium is at the upper end of normal, do you chose to give them saline or dextrose?

Answer 8

Dextrose

(make sure you try and add the amount you put in to how much they are loosing per 24hrs, e.g. if they loose 6L in a day, give 1L over 4hrs)

Question 9

by what increment should you increase phenytoin dose in a pt with chronically low sodium (from SIADH) who is experiencing seizures from previous excised meningioma?

could you switch it to carbamazepine?

Answer 9

THE LOWEST INCREMENT POSSIBLE9as with most PSA qus)

• do not switch to Carbamzepine as its a key cause of SIADH, would likely further lower the sodium which in itself would increase the risk of seizures

Question 10

how much maintenance fluis for adults and elderly? and which type?

Answer 10

adult (obese or not) : 3L IV maintenance fluid (equating to 8-hourly bags).
- elderly or very underweight = 2L (i.e. 12-hourly bags)

• aduults require 40-60mmol KCl per day when NBM

If biochem results normal, do one salt and two sweet (5% dex)

Question 11

What are the causes of hyperkalaemia? (think of a mneumonic!)

Answer 11

DREAD

D: drugs [K-sparing diuretics and ACE-i]
R: renal failure
E: endocrine [Addison’s disease: low aldosterone and/or cortisol]
A: artefact [VERY common, due to clotted sample]
D: DKA [note that when insulin is given to treat DKA the K drops requiring hourly monitoring +/- replacement]

Question 12

what is the treatment alogrhythm for anaphlaxis?

Answer 12

1. ABC & O2 (15L) by non-rebreather mask (unless COPD)
   - Hx, O/E, Ix, remove cause
2. Adrenaline 500mcg of 1 :1000 IM
3. Chlorphenamine 10mg IV
4. Hydrocortisone 200mg IV
5. Asthma Tx if wheeze

Question 13

Mx of T2DM if lifestyle Mx fails to help

Answer 13

Biguanide (metformin)

!! but CI’d in pts with eGFR <30mL, or Cr >150, or normal/low weight

• because of increased risk of lactic acidosis
• so use a SULPHONYLUREA (e.g. gliclazide) instead - but increased risk of hypo compared to metformin

Question 14

If patient with lower back pain has indigestion & constipation, and already on paracetamol, what options do you have for pain management?

Answer 14

• TCA, esp if element of depression is present
• opioids would need laxative too
• NSAID CI
• non-pharma treatments e.g. TENS

Question 15

How to relieve nausea and vomiting in small bowel obstruction (from adhesions from previous abdominal surgery)?

• metaclopramide 10MG IV
• haloperidol 500 mcg SC
• cyclizine 50MG PO
• large bore NG tube
• ondansetron 4MG orally

Answer 15

• M is a prokinetic type antiemetic : not appropriate [tries to make stomach contents empty faster into bowel]
• H : used as antiemetic in palliative care
• C : PO is CI
• • 1st line = remove the obstruction or decompress the system with a NG tube; give IV fluids too to prevent dehydration : “drip and suck”. If pt nauseated or NG intervention to possible then antiemetic medications should be used
• Ondansetron esp used for chemically induced N including chemo. PO unsuitable

Question 16

Pathway of Rx acute exacerbation of COPD

Answer 16

1. ABC
2. Hx, O/E, Ix
3. O2 (use 24% O2 firstly, if T2RF and non life-threatening observations- and carefully titrate with an ABG)
4. Salbutamol (5mg NEB)
5. Hydrocortisone 100mg IV (if severe/lifethreateniing) or Pred 40-50mg PO (if moderate - but takes a while to work)
6. Ipratropium 500mcg NEB (works quicker than the steroid)
7. Theophylline (only if life-threatening & senior colleague needed)

• also add Abx in somewhere if infective exacerbation

Question 17

What is ipratropium’s role in Mx of acute exacerbation COPD?

Answer 17

an anticholinergic and works in conjunction with salbutamol

Question 18

CPAP or BIPAP in resp failure?

Answer 18

BIPAP in t2RF

CPAP in T1RF

Question 19

Give 0.9% saline unless pit:
a.
b.
c.
d.

Answer 19

A. Is hypernatraemic or hypoglycaemic : give 5% dextrose instead

B. Has ascites (/in liver failure where low-sodium content is required): give human-albumin solution (HAS) instead. Albumin maintains oncotic pressure: and higher sodium content of 0.9% saline will worsen ascites

C. Is shocked with systolic BP <90mmHg: give gelofusine (a colloid) instead as it has a high osmotic content so stay intravascularly, maintaining BP for longer

D. Is shocked from bleeding : give blood transfuusion, but colloid first if no blood avaliable

Question 20

Difference in presentation of urticaria, angioedema, anaphylaxis

Answer 20

urticaria - itchy wheals

angioedema - swelling of tongue and lips

anaphylaxis - bronchospasm, facial + laryngeal oedenma, hypotension

anaphylaxis may initially present as urticaria + angioedema

Question 21

Pt has nut allergy, gets angioedema, paramedic already given him 500mcg (1:1000) adrenaline IM & high flow O2. He is starting to improve, but still has swollen face, hands and urticaria.

Next steps?

Answer 21

IV steroid and antihistamine

• IV hydrocortisone 200mg STAT
• chlorphenamine 10mg STAT
• fluid resus
• further adrenaline not appropriate as improving
• salbutamol not heplful as no wheeze

Question 22

Mx for acute pulm oedema?

Answer 22

IV loop diuretics e.g. furosemide

optimised on O2 first
- considered for NIV if they remain hypoxic on 100% O2 via non-rebreather mask

(bendroflumethiazide is usde in chronic hypertension & CCF, not acute pulm oedema)

Question 23

What is a common SE associated with ACE-i?

& other thing to counsel someone starting this medicine

Answer 23

Cough - thought to be due to build up of bradykinin

Often dose-dependent

If it occurs, a trial of an ARB is indicated

• caution should be taken if pt develops DorV, as increases AKI risk
• angio-oedema is a delayed reaction, typically occurs after months
• renal function and K tests should be done 1-2 weeks after initiation of therapy

Question 24

Adjustments in T1DM when unwell?

Answer 24

Basal blood glucose ^ therefore higher doses of insulin are required

failing to do so will ^ risk of DKA

Question 25

what can excessive alcohol intake result in for T1DM?

Answer 25

life-threatening hypoglycaemia

Question 26

Give some SEs of steroids : mneumonic STEROIDS | &BP

Answer 26

S Stomach ulcers T Thin skin E Oedema R Right & Left heart failure O Osteoporosis I Infection (including Candida) D Diabetes - Commonly causes hyperglycaemia & uncommonly progresses to diabetes S Cushings Syndrome Are also at risk of hypertension

Question 27

What Abx should not be used with methotrexate?

Answer 27

Folate antagonists such as trimethoprim and co-trimoxazole

Question 28

What monitoring needed for methotrexate?

Answer 28

regular blood tests every 3-4 weeks to monitor FBC, liver and renal function neutropenia is a common side effect pulmonary fibrosis is a potential SE

Question 29

Statins: a. what time of day to take? b. what SE can be a potentailly serious complication? c. can you use them in active liver disease? d. any dietary restrictions? e. give a drug they cant be taken with

Answer 29

a. at nighttime b. myositis > get medical help c. no, metabolism may be affected d. grapefruit juice should be avoided > inhibits CYP3A4, ^ statin toxicity e. clarithromycin (a CYP3A4 inhibitor), ^ toxicity related SEs

Question 30

What do you do about methotrexate in active einfection? and about regular prednisolone?

Answer 30

stop - it is contraindicated double steroids - sick day rules

Question 31

Name some commonly genertic drugs used for immediate releif of dyspepsia

Answer 31

magnesium carbonate aluminium hydroxide calcium carbonate (rennie is a mix of 1 and 3) PPIs , or H2 receptor antagonists (e.g. ranitidine) dont provide immediate relief

Question 32

can you give gaviscon, peptac or acidex to a pt | only medical history is thatthey're alergic to alginate dressings

Answer 32

no! these are oral alginates

Question 33

What drug to use for a UTI in someone on methotrexate and allergic to penicillin?

Answer 33

Nitrofurantoin | can't use trimethoprim or amoxicillin

Question 34

Cautions / contraindications for NSAIDs (use a mneumonic)

Answer 34

``` No urine - RF S - systolic dysfunction (HF) A - asthma I - indigestion (any cause) D - dyscrasia (clotting abnormality) ```

Question 35

Review date for most cases of IV Abx

Answer 35

after no more than 3 days | as most pts will be able to step down to PO

Question 36

Best Abx for severe HAP that is late onset (been a hospital IP for >5 days)

Answer 36

piperacillin with tazobactam (a broad spectrum cephalosporin) or a quinolone (e.g. cipro

Question 37

Main CI to stimulant laxative & give two examples & what time of day are they given

Answer 37

colitis or cramps senna or bisacodyl ON

Question 38

whats wrong with this prescription? 5-10mg oral nightly

Answer 38

(you must put a specific dose rather than a range of doses)

Question 39

Main CI to osmotic laxative | & example

Answer 39

bloating lactulose

Question 40

How do you weigh up the choice between codeine and tramadol?

Answer 40

likelihood of SEs both cause typical opiod SEs: resp depression, reduced consciousness and pinpoint pupils tramadol causes adgitation/hallucinations (esp in elderly) codeine is more constipating

Question 41

What observation parameter would be most beneficial in onitoring aminophylline's therapeutic effect in treatment of pt with severe asthma (when nebs and steroids prove inadequate) & which one to watch for toxicity? & when should blood samples be taken if given IV?

Answer 41

O2 sats HR - at toxic levels, A (a bronchodilator) causes tachycardia & can > fatal tachyarrhythmias 4–6 hours after starting treatment, unless toxicity concerns

Question 42

What obs parameter would help in monitoring an Abx's therapeutic effect on treating pneumonia

Answer 42

O2 sats, ABG > resp rate (CXR consolidation can take up to 6 weeks to clear - unhelpful in acute setting) (Creps would take several days to resolve)

Question 43

How to assess response of treatment of DKA

Answer 43

serum ketones (normalisation of this suggests cessation of ketogenesis) - serum glucose normalises rapidly after commencing an insulin sliding scale, but doesnt mean resolution of DKA (may still be acidotic and ketotic - need to motinor these and potassium)

Question 44

Why should pts with T2RF have lower target O2 sats? and what is the target generally?

Answer 44

Normally increased respiration (‘increased respiratory drive’) is triggered by hypoxia or hypercapnoea. In patients with chronic type 2 respiratory failure (and therefore chronic hypercapnoea) such as those with COPD, hypercapnoea no longer stimulates increased respiration, so they rely on hypoxia. This is why these patients should have lower target oxygen saturations (88–92%), because correcting their hypoxia (to >95%) can lead to a reduction in respiratory rate, subsequent increased hypercapnoea (because it is not being exhaled) and thus acidosis and carbon dioxide (CO2) narcosis.

Question 45

Before prescribing an ACE-i what one parameter is most important to check in primary care?

Answer 45

Renal function and electrolytes should be checked before starting ACE inhibitors (or increasing the dose)

Question 46

Should liver function be checked regularly during therapy with vancomycin? is peak or trough important?

Answer 46

no... clearance is principally renal TROUGH

Question 47

how might ACE-i induced renal impairment present?

Answer 47

often only as a 'malaise' so measure of serum k and Cr is necesssary before any dose titration

Question 48

what anti-hyperetensive os known to cause facial flushing?

Answer 48

CCBs - in a minority of pts starting new prescriptions

Question 49

how do opioids cause constipation?

Answer 49

slow transit through the bowel compounding this constipating effect is the increased time for reabsorption of water from the stool rendering the stool dehydrated and thus less mobile through peristalsis

Question 50

Give some SE of cyclizine

Answer 50

Antimuscarinic: urinary retention, constipation, blurry eyes, dry mouth, GI disturbances can worsen fluid rentention in HF (use metaclop instead)

Question 51

Allergic reaction after tazocin, only symptoms are pruiritis and macular rash on trunk

Answer 51

oral chlophenamine (will alleviate the pruiritis and acute presentation of a mild allergic reaction) no evidence of anaphylaxis so adrenaline and IV steroids are not indicated

Question 52

How to treat hypoglycaemia and at what level is it symptomatic?

Answer 52

normally <3 mmol/L - if pt is able to eat --> give sugar-rich snack e.g. OJ & biscuits (10-20g of glucose) - if drowsy/vom --> IV glucose via cannula e.g. 100mL 20% glucose (if not IV access --> IM glucagon 1mg)

Question 53

Drug for incontinence in pt with myaesthenia gravis

Answer 53

Duloxetine : - an inhibitor of serotonin and noradrenaline re-uptake [Oxybutynin - an antimuscarinic i.e. anticholinergic - should be avoided in myaesthenia gravis (where antibodies already block the Ach receptor and thus neuromusucular transmission) as will worsen the myasthenia]

Question 54

First line Abx for epiglottitis?

Answer 54

Cefotaxime

Question 55

antidepressant choice in OD

Answer 55

SSRI has lower toxicity in OD than tricyclics or venlafaxine

Question 56

47yr old acute gyane clinic with heavy periods and flooding GP has previously prescribed ferrous fumarate 200mgs OD and tranexamic acid 500mgs BD to use when on period Now 3 days into a heavy bleed and passing clots the size of a 50pence piece. Feels dizzy & lightheaded BP = 90/60. PR 80bpm, o2 sats 95% OA uterus is palpable abdominally & is 12 week size. Hb is 82 What 3 meds to prescribe today and what LT med to offer her?

Answer 56

1. Norehisteone (progesteone) to stop the bleeding 2. Tranexamic acid 1gm QDS to arrest bleeding 3. Ferrous fumarate 200mgs TDS to restore her bleeding PART B: Mirena IUS will take 3-4 months to control the bleeding - sometimes GnRH analogues used (but may make it worse at the beginning)

Question 57

Rx for urge incontinence. Has constipation what for atrophic vaginits?

Answer 57

dont use anticholinergics like oxybutinin - constipation!!! - MIRABEGRON avoids this Vagifem or Estriol cream