PSA Flashcards

Question

Drugs associated with hypokalaemia?

Answer 1

Salbutamol, insulin, diuretics (except K+ sparing)

Answer 2

thiazide diuretics

Answer 3

loop diuretics, bisphosphonates

Answer 4

Tetracyclines

Answer 5

sulphur-based drugs (sulphonamides, sulphonylureas), antiepileptics (gabapentin, lamotrigine, carbamazepine)

Answer 6

Opioids (codeine, tramadol) Anticholinergics (block acetylcysteine - neurotransmitter): * TCAs e.g. amitryptiline * Antihistamines e.g. chlorphenamine/cetirizine * Antiparkinsonian e.g. levodopa * Neuroleptics (antipsychotics) e.g. olanzapine, risperidone, chlozapine * Bladder instability e.g. oxybutynin

Answer 7

Anticholinergic drugs (TCAs, antihistamines, antiparkinsonian, antipsychotics, bladder instability) Opioids, Benzos (diazepam) Glucocorticoids (e.g. pred) esp. in elderly

Answer 8

Antibiotics Metformin PPIs Bisphosphonates SSRIs (citalopram, sertraline), lithium Colchicine, mg-containing drugs,

Answer 9

Anti-inflammatory meds (aspirin, ibuprofen, celecoxib) Bisphosphonates (alendronate) Corticosteroids (pred) Macrolides (clari) Metformin Theophylline

Answer 10

anti-HTN CNS suppressants (opioids, benzos, anti-depressants, anti-psychotics) Diuretics (furosemide)

Answer 11

Aminoglycosides (gent, cisplatin) Loop diuretics (furosemide) Phosphodiesterase type-5 inhibitors (tadalafil) - used for pul HTN

Answer 12

B-2-agonist (salbutamol) Levothyroxine, Lithium Cyclosporin Nicotine

Answer 13

Gastrotoxicity Renal impairment HTN

Answer 14

e.g. furosemide Dehydration Renal impairment Hypokalaemia

Answer 15

e.g. morphine Constipation Confusion Drowsiness Urinary retention

Answer 16

Baseline - BMI, blood lipids, fasting blood glucose, prolactin 1 month - fasting BM 3 months - BMI (check regularly until 3 months), blood lipids 4-6 months - fasting BM 6 months - BMI, blood lipids, prolactin Every year - BMI, blood lipids, fasting blood glucose, prolactin, FBC, U&E, LFTs

Answer 17

* Any bleeding: stop Warfarin AND _IV_ vit K slowly * **If major bleed = ADD dried PCC/FFP** * INR @24hrs --\> continue Tx if INR high, continue Warfarin when INR \<5 * INR \>8: stop Warfarin AND _oral_ Vit K * INR @24hrs --\> continue Tx if INR high, continue Warfarin when INR \<5 * INR 5-8: miss dose of Warfarin --\> reduce maintenance dose Target: 2.5 (2-3 range)

Answer 18

The units are UNITS (do not write an abbreviation)

Answer 19

POISONING in main bar --\> emergency treatment

Answer 20

ACUTE: * Burst: * **SABA** (spacer up to 10 puffs every 20 mins --\> nebs) * **Ipratropium Bromide** (add to nebs if poor response/severe, every 4-6hrs) * **Corticosteroids** (min 5-day course, give within 1 hour, give IV if can't take orally) * Other Tx options: * **IV Magnesium sulfate** (STAT dose if poor response above/severe) - _consult senior_ before use * **IV salbutamol** (if on ventilation) - _consult senior_ before use * **IV Aminophylline** - consult senior before use, requires _ITU setting_ **Long-term Mx (\>16yrs):** * SABA**SABA** (reliever) * SABA + **_ICS_** (preventer) * SABA + ICS + **_LTRA_** (leukotrine receptor antagonist e.g. montelukast) * SABA + ICS + **_LABA_** (+ LTRA stopped unless good response) * SABA + **MART** (ICS + LABA COMBO) (+ LTRA) * NOTE: maintenance & reliever therapy (MART) - used as preventer & maintenance inhaler * Specialist input (e.g. for oral steroids)

Answer 21

Medical pathway: * 1 - SABA/SAMA (ipratropium) * 2a - **Steroid-responsive** (eosinophilia/atopy): LABA + ICS * 2b - **Not steroid-responsive:** LABA (salmeterol) + LAMA (tiotropium) * 3 - LABA + LAMA + ICS * 4 - specialist input e.g. theophylline **Acute Exacerbation Mx:** * 15L O2 NRM * Nebs - salbutamol + IpB * Steroids (PO pred/IV hydrocortisone) * Abx if infective --\> prophylactic abx if persistent infections - azithromycin

Answer 22

Drug-drug interaction --\> risk of liver damage + rhabdomyolysis ## Footnote **Withhold atorvastatin**

Answer 23

1. Parkinson's drugs (Levodopa, Carbidopa) 2. Antiepileptics (Na Val, Carbamazepine, Lamotrigine, Levetiracetam) 3. Antiretrovirals (-avir) 4. Steroids (long-term) - stopping abruptly --\> Addisonian crisis Routes --\> patches, IV, NG tube

Answer 24

**Strength:** * Weak - codeine, dihydrocodeine * Moderate - tramadol (surgeons love) * Strong - morphine, oxycodone, buprenorphine, fentanyl **Oral morphine has 2 forms:** * Oral morphine has 2 forms: * Immediate-release (e.g. oromorph) - max 4-hourly * Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD) **Guide to morphine:** 1. If can't tolerate oral e.g. vomiting alot --\> **oral dose/2 = IV dose** 2. Immediate-release PRN (max 4-hourly) --\> see how much using 3. If using a huge amount --\> convert to modified-release (12/24-hourly): * **Add up total daily PRN dose = X** * **24-hourly = X (OD); 12-hourly = X/2 (BD)** **When to give oxycodone:** renal impairment (eGFR \<30mL/min) * Immediate-release: oxycodone oral solution, oxynorm * Modified-release: oxycontin * NOTE: same logic as above **Breakthrough analgesia:** * Oral morphine/oxycodone * 1/10-1/6 of total daily dose of modified-release morphine **_Example: 60mg Oromorph --\> 30mg MST BD + 6-10mg breakthrough dose_** **Conversion** - 10mg oral morphine: * Oxycodone - 5mg oral **(x/2)**, 2.5mg IV **(x/4)** * Tramadol/Codeine - 100mg oral/IV **(x\*10)** - NOTE: codeine has no IV option

Answer 25

**Tx: IV FLUIDS** (rehydrate) - after initial bolus give _1L 0.9% saline + 40mmol KCl over 1hr_ **Tx: 0.1 U/kg/hr fixed-rate INSULIN** **infusion** (reduce ketones) + _add IV 10% dextrose_ on reducing ketone/glucose levels * Insulin infusion continues even if BM normalises --\> to inhibit lipolysis & prevent ketone formation (can consider stopping once ketones normal) * Stop short-acting insulin, maintain background insulin * NOTE: follow local trust guidelines for DKA Tx as varies slightly between trusts

Answer 26

IV access --\> STAT dose naloxone 400mcg - after 1-min of no improvement --\> 800mcg Stay by the bedside until improved resp rate If the patient becomes unrousable again - Naloxone has a short half-life so may still be opioid toxic --\> Naloxone infusion

Answer 27

**IM 0.5mg adrenaline (1:1000)** **IV 10mg chlorpheniramine** **IV 100mg hydrocortisone** Treat bronchospasm – salbutamol +/- ipratropium

Answer 28

Crohn's & UC Mx (Crohn's = steroids --\> methotrexate; UC = 5-ASA): * Induction: * Steroids (induce remission) * 5-ASA (mesalazine) * Maintenance: * Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine) * Biologics e.g. Anti-TNF (infliximab)

Answer 29

Drugs with prognostic benefit: * IV Terlipressin (ADH analogue --\> vasoconstriction)/Somatostatin (used for same reason) * Prophylactic abx - Ceftriaxone/Norfloxacin (abx)

Answer 30

Mx: consider **STOPPING NSAIDs** * stop NSAIDs * If H. pylori +ve: **triple therapy for 7 days** (**PPI** + 2 abx = **Amox** + **clari**/metro) * If pen allergic --\> PPI + Clari + Metro * If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist e.g. cimetidine)

Answer 31

**Stable angina:** * B-blockers - reduces HR req for activity --\> reduced likelihood of mismatch in O2 supply & demand * GTN spray - reduce myocardial preload + reduces strain * RF modification --\> reduced risk of progression **Acute coronary syndrome** - Sx caused by sudden reduced BF to the myocardium * Generic ACS Mx - MONA BASH * ALL immediate: * 5-10mg Morphine IV + Nitrates (GTN spray) * Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor) * ALL long-term: * Continue DAPT * 1 year: _75mg_ OD Aspirin + _75mg_ OD Clopidogrel (or 90mg BD Ticagrelor) * \>1yr - **_75_**mg OD Aspirin * B-blocker (1.25-10mg Bisoprolol OD) * ACEi (1.25-10mg Ramipril OD) * Statin (80mg Atorvastatin OD) * STEMI Mx: establish coronary reperfusion ASAP * Sx \<12hrs: **_PCI_** BUT if no PCI within 2hrs Dx --\> thrombolysis (e.g. tPA - tissue plasminogen activator) * Sx \>12hrs: invasive coronary angiography ± PCI if needed * PCI: * If having PCI give **_Prasugrel_** (instead of Clopi/Ticagrelor) * PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND **_IV unfractionated heparin_** during the procedure --\> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) --\> takes longer for endothelialization of stent so DAPT needed for 1yr * NSTEMI Mx: 2.5mg SC Fondaparinux (direct factor 10a inhibitor)

Answer 32

**Mx:** MON BA (out of MONA BASH) * Immediate: * Sit the patient up (reduce venous return to heart --\> less strain) * O2 15L/min NRM * Medical: * **_IV_ furosemide** (loop diuretic) - remove excess fluid + venous dilation (reduce preload) * _Nitrates_ (GTN/Isosobide Mononitrate) AND _Morphine_ - reduce preload on the heart * Long-term: * Reduced ejection fraction - prognostic benefit: * **B-blocker** (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them * **ACEi** - reduce strain on heart * After the above if LVEF \<35% & Sx --\> mineralocorticoid antagonist e.g. **_spironolactone_** * 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT * **SGLT2 inhibitors** (dapagliflozin) * RF modification - poor glycaemic control/high cholesterol * Sx - diuretics e.g. furosemide

Answer 33

**Mx:** * Haemodynamically unstable --\> synchronised DC Cardioversion * _Vagal manoeuvres_ (increase parasympathetic stim via vagus nerve to slow conduction via AV node) * Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe * **Adenosine** 6mg --\> 12 mg --\> 12mg * NOTE: if adenosine CI (e.g. asthma) --\> _VERAPAMIL_ (rate-limiting CCB) * Other: * IV B-blocker/amiodarone/digoxin * Synchronised DC Cardioversion

Answer 34

**Mx:** * Haemodynamically unstable (≤90 BP, chest pain, acute HF) --\> DC Cardioversion OR * Rate control --\> **B-blocker** (bisoprolol) OR rate-limiting CCB (verapamil - asthma) OR * Rhythm control - ONLY if clear reversible cause * Sx onset **\<48hrs** --\> **DC/chemical cardioversion** (amiodarone/flecanide) * NOTE: IV heparin started prior to cardioversion * Sx onset \>48hrs --\> _anticoagulate for 3wks_ --\> elective cardioversion (also anticoag for 4wks after) AND * Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score --\> DOAC (Apixaban) * If metallic heart valve --\> warfarin INR 3-3.5 * Otherwise DOAC * NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 --\> anticoagulation not recommended * **C**HF, **H**TN, **A**ge ≥75rs (2), **D**M, **S**troke (2), **V**ascular disease, **A**ge 65-74, **S**ex - female * Score 1 - consider; ≥2 - DOAC/Warfarin needed

Answer 35

**Heparins** * LMWH (SC) - VTE prophylaxis BUT bad for renal function * UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring **DOACs** - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD) **Vit K antagonist** = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions

Answer 36

**Initial Tx:** * **DOAC** (e.g. Apixaban) or unfractionated heparin (if bleeding risk, can be reversed easily) * Massive PE --\> IV unfractionated heparin for hours before and after **thrombolysis** e.g. IV alteplase **Ongoing anticoagulation - DOAC/Warfarin** * Provoked - 3 months (SICC) * Unprovoked - \>6 months + cancer & thrombophilia testing

Answer 37

BP targets: * \<140/90 * \<150/95 if \>80yrs Drug treatment: * 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan) * 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide) * 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_ * 3. ACEi + CCB + thiazide diuretic * 4. Add: * Spironolactone (or other diuretic) * Alpha-blocker * Beta-blocker * Specialist advice

Answer 38

T1DM Mx: **_exogenous insulin_** to avoid DKA & long-term complications * BM targets - fasting BM: * Waking: 5-7mmol/litre * Before meals: 4-7mmol/litre * Insulin regimens: * 1st line - **Basal-bolus regimen** * Basal (background) - BD insulin detemir as basal insulin * Bolus (before meals) - analogue rapid-acting insulin e.g. insulin lispro * Other: * BD biphasic (premixed insulin, hypos common) * OD before bed long-acting (for T2DM) T2DM Mx: * 1st line - Lifestyle changes - DESMOND course for T2DM, dietician input, self-BM monitoring (individual HbA1c target \<6.5) * Medication: * 2nd - **Metformin** (SEs: LA - avoid if eGFR \<30) * 3rd - ADD **Sulphonylurea e.g. Gliclazide** (SEs: hypoglycaemia, weight gain) * 4th - ADD other DM med: * **Pioglitazone** (SEs: hypoglycaemia, weight gain, oedema, fractures in elderly) * C/I in HF, bladder cancer * **SGLT-2 inhibitor e.g. Empagliflozin** (SEs: Hypoglycaemia, weight loss, UTI) * Not recommended in impaired renal funct * **DPP-4 inhibitor e.g. Linagliptin** (APPROVED FOR USE IN **_CKD_**, weight neutral) * **GLP-1 analogues e.g. Exenatide/Liraglutide** (SE: weight loss - useful if BMI \>35; vomiting) * Not recommended in impaired renal funct * 5th - If on triple therapy & not providing control --\> commence **_insulin_**

Answer 39

e.g. dapagliflozin Increased yeast/UTIs, hypoglycaemia, weight loss

Answer 40

hypoglycaemia, weight gain, fluid retention (oedema), assoc with bladder cancer, osteoporosis (elderly - fractures) C/Is: HF, bladder cancer

Answer 41

Variable insulin infusion for 30-60 mins after starting SC insulin to avoid iatrogenic DKA

Answer 42

Weight gain & hypoglycaemia

Answer 43

If poorly controlled DM (HbA1c ≥69) or _long starvation period_ (≥2 missed meals) --\> **variable rate insulin infusion + IV maintenance fluids** (5% glucose in 0.45% saline) If on insulin: * If using **variable rate insulin infusion** - stop all insulin until eating/drinking normally and has been 30mins since first post-op insulin dose * Basal (background insulin) always maintained to prevent ketosis - dose reduced by 20% to avoid hypoglycaemia * Bolus (before meals) avoided: * If AM surgery - omit morning & lunch dose * If PM surgery - omit lunch dose If on diabetic medications: * Stop ALL if variable-rate insulin infusion used - apart from GLP-1, which can be maintained * Insulin & sulphonylureas (glipizide) - dose must be reduced as they lower BM --\> hypoglycaemia * AM surgery - omit morning dose * PM surgery - omit morning and afternoon dose * Metformin, GLP-1 analogues (liraglutide), DPP-IV inhibitors (linagliptin), SGLT2 inhibitors (dapagliflozin) - rarely cause hypoglycaemia while fasting (only reduced if other concerns) * SGLT2 inhibitors - omit morning dose if AM/PM surgery NOTE: take all as normal day before admission, take as normal day after surgery

Answer 44

ASK PATIENT - rule of thumb is 100/total daily dose (TDD) * E.g. TDS Actrapid 7 units + 18U lantus = 39U TDD --\> 100/39 = 2.5 * Generally it is roughly 3mmol/L 10% Target glucose: 4-10 (aim for 7-8) - if on insulin: * Waking 5-7, otherwise 4-7

Answer 45

e.g. linagliptin Approved for use in CKD

Answer 46

e.g. exenatide/liraglutide Induces weight loss (good for BMI \>35, \>30 + comorb) Vomiting SC inj

Answer 47

0 to -2.5 DEXA: conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes * Repeat DEXA @2yrs * 1st line - Bisphosphonates PO (e.g. alendronic acid) --\> if not tolerate can trial Denosumab/Raloxifene/Teriparatide * Vit D + Ca replacement (if inadequate sunlight/intake exposure) * Review Tx every 3-5yrs NOTE: * If premature menopause --\> discuss HRT * If on high-dose CS (≥7.5mg OD for ≥3 months) --\> consider bisphosphonates for bone protection Osteonecrosis of the jaw

Answer 48

**Mx:** * Medical: * _Alpha-blocker_ (relax sm muscle around prostatic urethra) e.g. **tamsulosin** * _5-alpha-reductase inhibitor_ (reduce conversion of testosterone --\> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. **finasteride**

Answer 49

Mx: * Identify & Mx the cause * Hypovolaemic - IV fluid bolus * Hypervolaemic - if pul oedema --\> loop diuretic (furosemide) + Na restriction

Answer 50

Mx: * **Bronchiolitis** (from RSV, \<1yr) - conservative (simple analgesia) + Palivizumab for prevention * **Croup** - oral dexamethasone 0.15mg/kg + neb O2 & adrenaline

Answer 51

* \<5yrs: * 1^st line – SABA (reliever) * 2^nd line – if atopic --\> **_8wk trial medium-dose_ ICS** (preventer) * 3^rd line * Steroid-unresponsive (recurrent Sx \<_4wks)_ --\> **low-dose ICS** * Steroid-responsive (recurrent Sx _\>4wks_) --\> another _8wk course_ **medium-dose ICS** * 4^th line – **LTRA** * 5^th line – specialist advice * 5-16yrs: * 1^st/2^nd line - If SABA insufficient to control symptoms or bad enough symptoms at first presentation give SABA + ICS (morning and evening everyday 1 puff) * 3^rd line - **Leukotriene receptor antagonist (e.g., montelukast)** --\> block pro-inflam cytokines from arachidonic acid pathway (w/ COX) * 4^th line - If LTRA not working add on **LABA** (either continue/discontinue LTRA) * 5^th - If doesn’t work start **maintenance & reliever therapy (MART) = 1 inhaler with ICS + LABA** (morning and evening everyday) + used for relief as well instead of SABA inhaler * 6^th line – **OCS** * 7^th line – specialist advice

Answer 52

Adults: standard-dose PPI ± H2 antagonist (Cimetidine)

Answer 53

* On exam feel for impacted stool * Dig into social aspects of constipation – look for precipitants e.g., diet, difficulty outside on home --\> consider in conservative management * Osmotic laxative --\> water moves into intestinal lumen from surrounding tissues * Stimulants --\> contraction of intestines helping to pass bolus of faecal matter

Answer 54

Stress-incontinence (leak on laugh/cough): pseudoephedrine (2nd - Duloxetine) Urge-incontinence (preceded by the urge to pass urine): anticholinergic e.g. Oxybutynin (not if \>80yrs), Tolterodine Overactive bladder syndrome (urge but not incontinence - increased freq + nocturia): same as urge incontinence

Answer 55

Fibroids: * Tranexamic acid - for haemorrhagia * NSAIDs (mefenamic acid) - for pain relief * OCP/marina coil - if don't want pregnancy * Progestogens (norethisterone) for acute bleed Endometriosis: * NSAIDs * Hormonal: * COCP/progestogen-only OCP, levonorgesterol-IUD (mirena coil), implant * GnRH agonist

Answer 56

COCP (or Marena coil) Fertility: ovulation induction e.g. clomifene

Answer 57

HRT: see 'sex hormones' on medicines complete - search estradiol/estradiol with norethisterone * If hysterectomy --\> oestrogen-only OD (estradiol) * Cyclical (have menses): * Regular - estradiol OD, progestogen (norethisterone) on last 14 days of cycle * Irregular - estradiol OD, norethisterone on month when have period * Continuous - estradiol & norethisterone OD after 1yr cyclical therapy/no withdrawal bleeding (established menopause) * Vaginal atrophy --\> topical estradiol SEs: breast cancer (combined), VTE risk (not patches) * Reduced risk of osteoporosis

Answer 58

Conservative – compression stockings + elevation LMWH throughout pregnancy + 3-months post-partum

Answer 59

Medical: Syntocinon IV

Answer 60

Control BP – oral Labetalol/Nifedipine (severe – IV labetalol/hydralazine) Prevent seizures – IV Magnesium Sulfate

Answer 61

Conservative - ginger, pressure point Medical: * If no volume depletion: * Doxylamine (vit B6) &/or pyridoxine (anti-histamine) * 2nd - metoclopramide * If volume depletion: * IV fluids * IV metoclopramide ± PPI (omeprazole) Other: * Thiamine supplementation (B1, 1/wk) --\> wernicke's * Thromboprophylaxis (LMWH + stockings due to bed rest, lack of movement)

Answer 62

misoprostol (vaginal pessary or oral)

Answer 63

\<9wks - oral mifepristone, followed 24-48hrs by oral misoprostol

Answer 64

Local: clotrimazole pessary (e.g. clotrimazole 500mg PV stat) * If preg can only use local Tx Oral: * Itraconazole 200mg PO BD (for 1 day) * Fluconazole 150mg PO stat

Answer 65

Antihypertensives * ACEi (not in pregnancy) - Ramipril * B-blockers (IUGR, bradycardia - possibly in pregnancy) - Atenolol, Labetalol (not known to be harmful except possibly in 1st trimester) * Ca-channel blockers - Nifedipine (fine in all trimesters, but possible tocolytic effect, avoid before week 20, only use if other options have failed) * Methyldopa (not known to be harmful during pregnancy) BUT often does not provide reasonable hypertensive control * Balanced approach (risk of foetus vs hypertension in mother): * Can control tocolytic effect by increasing oxytocin during labour * Typically Labetalol and Nifedipine are used Alcohol * NOT DURING PREGNANCY (the odd drink very rarely is fine) Anti-epileptic * Sodium Valproate = VERY BAD (teratogenic), currently thought to be fine in breast feeding * Examples can switch to —\> Lamotrigine, Topiramate

Answer 66

Meningitis & encephalitis Mx: * Suspected in primary care - **IM/IV Benzypenicillin** * Secondary care - **IV Ceftriaxone** _± Amoxicillin_ (infants/\>50yrs) * If could be encephalitis (seizure/behavioural) - _IV Aciclovir_ GCA Mx: **high-dose Prednisolone** ± alendronic acid (if long-term steroids) Migraine Mx: * Acute - simple analgesia + **_Triptans_** (take as soon as Sx start) * Prevent - trigger avoidance + **propranolol**/ **topiramate** (anticonvulsant) /**amitriptytline** (TCA)

Answer 67

**Ischaemic:** * **Immediate:** * **Aspirin 300mg** OD + _STOP_ anticoagulants (high risk of haemorrhagic transformation in first 2wks) * \<4.5hrs since Sx onset: **thrombolysis** (Alteplase = tPA) * \>4.5hrs since Sx onset: conservative Mx * **After 2wks:** * STOP aspirin --\> start **clopidogrel 75mg OD** + consider _anticoagulation_ (e.g. if AF) - DOAC/Warfarin

Answer 68

**Mx:** problem = lack of dopamine in substantia nigra --\> aim of Tx is to increase dopamine here * **Dopamine agonist** (cross BBB) --\> Ropinirole /Pramipexole /Apomorphine * '**L-DOPA AND peripheral DOPA-decarboxylase enzyme (Carbidopa)**' --\> Co-Beneldopa (Madopar)/Co-Careldopa (Sinemet)

Answer 69

Types: * **Generalised** (whole brain): * Tonic-clonic, Tonic, Atonic, Myoclonic --\> Tx: _Na Valproate_ (AVOID in girls/women of childbearing age) * Absence --\> Tx: _Ethosuximide_/Na Valproate * **Focal** - aware (conscious) OR impaired awareness (impaired consciousness) * Tx: _Lamotrigine_ Status epilepticus = \>5mins/repeated seizures without full recovery in between * 1st - IV lorazepam 4mg --\> repeat * 2nd - phenytoin infusion * 3rd - general anaesthesia * If no IV access --\> rectal diazepam/buccal midazolam

Answer 70

Tx: _Acetylcholinesterase inhibitors_ (_Donepezil_, galantamine, rivastigmine)/NMDA receptor antagonists (Memantine)

Answer 71

Mx: * Pred (if \<72hrs Sx onset) * Severe palsy/complete paralysis --\> concurrent antiviral therapy (aciclovir), surgical decompression

Answer 72

systemic antibiotic e.g. erythromycin, flucloxacillin

Answer 73

CAP: * Typical (S. pneumo, H. influenzae) --\> Amox/Co-Amox * Atypical (Legionella, Mycoplasma, Chlamydia) --\> Clari * NOTE: if not sure often given Co-Amox + Clari HAP - pneumonia arising \>48hrs after admission to hospital (S. pneumo, S. aureus, P. aeruginosa) --\> Taxocin (pseudomonal cover)

Answer 74

**Fluid status:** * **HYPO**volaemic (dehydrated) - _WASTING_ (diarrhoea/vomiting, diuretics) --\> **IV fluids** * **EU**volaemic (normal) - _ENDOCRINE_ (SIADH, hypothyroidism, Addison's) --\> **fluid restrict** * **HYPER**volaemic (fluid overload) - _FAILURE_ (liver, renal, heart) --\> **fluid restrict + Tx underlying cause** Na corrected too fast (\>10) = osmotic demyelination syndrome (central pontine myelinolysis) --\> pseudo-bulbar palsy, paraparesis, locked-in syndrome

Answer 75

**Hyperkalaemia Tx:** * **Protect heart** - **IV 10-30ml _10% Ca Gluconate_** (repeat /15m, x5 MAX) * **Reduce K⁺:** * 1st line - **_10U Actrapid_** (insulin \> drive K into cells) **AND _100mL 20% glucose_** (to prevent hypo) * 2nd line - 5mg Salbutamol NEB (b-agonist) * **Ix cause:** drug chart, U&E (kidney funct), short SynACTHen test (Addison's)

Answer 76

**Hypothyroidism** Mx: * Thyroid replacement therapy (levothyroxine) * Myxoedema coma - A-E & active warming, T3 slow IV, hydrocortisone IV **Hyperthyroidism** Mx: * **Medical:** * Sx relief – _B-blockers_ * Antithyroid meds - _Carbimazole_ (or propylthiouracil) * SEs: rashes, agranulocytosis - monitory * **Thyroid storm:** acute state of shock, pyrexia, confusion, vomiting * _Propylthiouracil_ 600mg --\> 200mg QDS

Answer 77

**HYPERcalcemia** * **Sx:** * Stones - urinary tract calculi * Bones - fractures * (Abdo) moans - dyspepsia * Thrones - polyuria, constipation * (Psych) overtones - depression, psychosis * Mx: * IMMEDIATE = **aggressive IV 0.9% fluid resus** (4-6L over 24krs), repeat Ca **HYPOcalcaemia** * Presentation: * Peri-oral numbness, digital paraesthesia, dermatitis * +ve _Trousseau's_ (BP cuff 20 over SBP for 3mins --\> salt bae hand), _Chovstek signs_ (tap over the masseter muscle in the inferior pre-auricular area) * Laryngospasm (wheeze, dysphagia, muscle cramps) * Confusion, seizures, prolonged QT * Mx: PO/IV replacement of Ca

Answer 78

Medical (none proven to provide sustainable weight loss) * **Orlistat** (gut lipase inhibitor, SEs: profound flatus, diarrhoea)

Answer 79

Medical – analgesia (paracetamol/NSAID), IA CS injection * Paracetamol --\> topical NSAIDs --\> oral NSAIDs

Answer 80

Presentation: 1st MTP joint, monoarticular (can be poly) Mx: * Acute: * NSAIDs, Colchicine * Oral Pred (5 days), steroid joint injection * Chronic: * Xanthine oxidase inhibitor e.g. allopurinol

Answer 81

1st - statins e.g. atorvostatin 2nd - lipid-regulating drug e.g. ezetimibe

Answer 82

Mx bacterial: topical azithromycin * Viral/allergic - topical antihistamine e.g. epinastine

Answer 83

Presentation: blurring of vision, painful red eye, headache, N&V Mx: 1st line: * **Carbonic anhydrase inhibitors** (acetazolamide) AND/or * **Topical beta-blockers** (timolol) AND/or * **Topical alpha-2 agonists** (brimonidine)

Answer 84

ACUTE (PAINFUL CRISES) * Oxygen * IV Fluids * Strong analgesia (IV opiates) * Antibiotics * Cross match blood * Give transfusion if Hb or reticulocytes fall sharply

Answer 85

Presentation: muscle aches and joint stiffness * Difficult to rise from seated/prone position * Shoulder/hip stiffness & bursitis * muscle tenderness & oligoarthritis Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates) * Other: methotrexate + folic acid

Answer 86

Oxycodone \> morphine if renal impairment Do not give NSAIDs in asthma/renal impairment/elderly/pregnant Neuropathic pain does not respond to opioids

Answer 87

Responds well to PR NSAIDs (diclofenac)

Answer 88

Carbamazepine 1st line for neuropathic pain

Answer 89

duloxetine

Answer 90

**Blood transfusion threshold:** Hb \<70 or \<80 _AND_ ACS * Other options: Fe infusion, ferrous fumarate

Answer 91

Fentanyl, Buprenorphine Oxycodone can be used if eGFR 30-60 (still partially renaly excreted)

Answer 92

Anxiety/distress: _Midazolam_ 2.5-5mg SC 1-2hrly PRN Secretions/colic: _Glycopyrronium_ 0.2-0.4mg SC QDS PRN Nausea & vomiting: _Haloperidol_ 0.5-1.5mg SC BD PRN (max 5mg/24hrs) * Could give **Cyclizine** 50mg SC TDS PRN Pain: _Morphine_ 2.5-5mg SC 1-2hrly PRN (or Oxycodone 1.25-2.5mg)

Answer 93

Glycopyrronium 0.2-0.4mg SC QDS PRN

Answer 94

PHOMO (C not O) Prochlorperazine for _vestibular causes_ Haloperidol for _IC causes (raised ICP/tumour)/palliative_ Ondansetron for _chemo-induced nausea_ Metoclopramide for _GI causes_ Cyclizine if risk of _EPSEs/QT prolongation_

Answer 95

SEARCH "Genital System Infections" * **Chlamydia** (Chlamydia trachomatis) – obligate intracellular G-ve (can’t be cultured on agar) * Mx: **Azith 1g STAT**/Doxy 100mg BD 7 days * **Gonorrhoea** (Neisseria gonorrhoeae) – obligate intracellular G-ve diplococcus * Mx: **ceftriaxone 250mg IM STAT** * **Syphilis** (Treponema pallidum) – obligate G-ve spirochaete * Mx: **IM Ben Pen STAT** * **Bacterial vaginosis** - fish-like odor, thin/off-white discharge, clue cells, mild irritation * Mx: **Metro** (top/oral) OR clindamycin (top) * **Trichomoniasis** (parasite) - musty odor, pale green discharge, strawberry cervix, motile flagellated protozoa, dysuria/tenderness/itchy * Mx: **Metro** (oral)

Answer 96

1st - Bulk laxative e.g. fybogel (ispghula husk)/methylcellulose 2nd - Osmotic laxative e.g. lactulose/movicol/polyethylene glycol 3rd - Stimulant laxative e.g. Senna

Answer 97

**ART first line:** * **2 NRTIs** (tenofovir & abacavir) * AND **NNRTI** (Efavirenz)**/PI** (Ritonavir)**/Integrase inhibitor** (Raltegravir) Pneumocystis pneumonia (PCP) --\> co-trimoxazole

Answer 98

Rifampicin & Isoniazid (6 months), Pyrazinamide & Ethambutol (2 months)

Answer 99

* Single topical therapy: topical retinoid or benzoyl peroxide * Topical combination therapy (choose 2 or more): topical retinoid, benzoyl peroxide, topical antibiotic * Add oral antibiotics: _tetracycline_, macrolide, trimethoprim * (Sometimes COCP as alternative in women) * Oral isotretinoin

Answer 100

Emolients MILD: hydrocortisone 1% MODERATE: **betamethasone** **valerate 0.025%** OR **clobetasone** **butyrate 0.05%** SEVERE: **betamethasone valerate 0.1%** --\> oral corticosteroids Infected eczema --\> PO Flucloxacillin

Answer 101

Infant - topical imidazole cream (Clotrimazole 1%) Adolescent - ketoconazole 2%

Answer 102

Intranasal CS e.g. betametasone nasal Oral AH e.g. citirizine

Answer 103

**WARFOAC:** * **W**arfarin needs daily INR monitoring if on: * **A**bx * **R**egular tramadol * **F**luconazole * **O**meprazole * **A**miodarone * **C**orticosteroids (high dose)

Answer 104

Normal requirements if NBM: * H20 - 25-30ml/kg/day (cardiac disease is 20-25) * Na/K/Cl - 1mmol/kg/day * Glucose - 50-100g/day (prevent ketosis) * UO should be \>0.5ml/kg/hr Maintenance fluids - traditional fluid regimen of '1 salty + 2 sweet' * 1L saline 0.9% + 20mmol KCl (over 6-8hrs) * NOTE: contains 154mmol Na/Cl in 1L bag * **2x** 1L dextrose 5% + 20mmol KCl (over 6-8hrs) * NOTE: on medicine complete written as glucose 5%/potassium chloride 0.15% (0.3% if want 40mmol KCL) * NOTE: surgeons often prescribe Hartmann's instead of NaCl as isotonic --\> less likely to cause hyponatremia (above regimen provides too much H2O & too much Na) Resus fluids - 500ml fluid bolus 0.9% NaCl over 15-20 minutes (250ml if HF)

Answer 105

Septic shock = sepsis + haemodynamic instability Neutropenic sepsis: * Neutrophils \<0.5 * Temp \>38 degrees * Tx = Tazocin

Answer 106

3 in, 3 out All within 1hr

Answer 107

* Create an end target e.g., remission * 1st - Monotherapy with conventional DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved ± NSAIDs - Sx Mx (ibuprofen/naproxen) * Target met? * Yes = keep drug regime + lifestyle changes * No = titrate cDMARD/trial alternative cDMARD ± dual therapy * Target met? * Yes = keep drug regime + lifestyle changes * No = biological agents if DAS28 score \>5.1 (severe burden of disease)

Answer 108

Fluclox (clari if pen allergy)

Answer 109

CENTOR/FeverPAIN score Tx: Phenoxymethylpenicillin (Clari if pen allergic)

Answer 110

Prophylaxis & treated = Co-amoxiclav

Answer 111

Antiviral ointment e.g. aciclovir If necrotising stromal keratitis --\> Steroid eyedrops e.g. dexamethasone (only by specialist)

Answer 112

Amoxicillin

Answer 113

Presentation: chest/back/neck/proximal arms * Dyspigmentation * Macules/patches * Fine overlying scale Skin scrapings: short hyphae and budding yeast with spaghetti-and-meatballs appearance Tx: anti-fungal e.g. ketoconazole 2% shampoo

Answer 114

LMWH e.g. dalteparin & TED stockings

Answer 115

**HYPERcalcemia** * **Sx:** * Stones - urinary tract calculi * Bones - fractures * (Abdo) moans - dyspepsia * Thrones - polyuria, constipation * (Psych) overtones - depression, psychosis * Mx: * IMMEDIATE = **aggressive IV 0.9% fluid resus** (4-6L over 24krs), repeat Ca * Tx underlying cause: * Parathyroid adenoma - minimally invasive surgery (subtotal/total parathyroidectomy) * Malig - _Pamidronate_ (inhibit osteoclast activity), slow infusion * Other: * If bone mets --\> _bisphosphonates_ * If renal failure --\> _Cinacalcet_ (reduce PTH) **HYPOcalcaemia** * Presentation: * Peri-oral numbness, digital paraesthesia, dermatitis * +ve _Trousseau's_ (BP cuff 20 over SBP for 3mins --\> salt bae hand), _Chovstek signs_ (tap over the masseter muscle in the inferior pre-auricular area) * Laryngospasm (wheeze, dysphagia, muscle cramps) * Confusion, seizures, prolonged QT * Mx: PO/IV replacement of Ca

Answer 116

Propranolol If GAD Sx --\> SSRI

Answer 117

Oral doxycycline for 21 days If CNS involved use IV ceftriaxone instead

Answer 118

Broad-complex irregular tachycardia where the size and shape of the QRS varies complex to complex within any given lead (polymorphic) * Increased QT interval increases the risk e.g. drugs (clari, amiodarone) Magnesium sulfate IV 2g over 10 minutes

Answer 119

Addison's disease - adrenal insufficiency * Presentation: Anorexia/weight loss, fatigue/weakness, postural dizziness, reduced libido, sweating * N&V, diarrhoea, salt craving * Signs: hyperpigmentation in skin creases/lip/mouth, vitiligo, sparse axillary/pubic hair * Ix: short synACTHen test * Mx: IV fluids --\> IV hydrocortisone ± fludrocortisone (if primary adrenal lesion) Conn's/bilateral adrenal hyperplasia - high aldosterone * Ix: aldosterone-renin ratio (ARR) - Conn's has high aldosterone, low renin; BAH has both high * Mx: spironolactone

Answer 120

If Sx have not improved for 24hrs while continuing to express milk --\> Flucloxacillin

Answer 121

Low K, Mg, PO4, Ca, Na + fluid overload * Carefully reintroduce nutritional support * Correct electrolyte abnormalities

Answer 122

Normal: ≥10 on room air On Oxygen: PaO2 (kPa) should be 10 less than FiO2 (level of oxygen they are on %)

Answer 123

Oxygen from wall = 100% Peak inspiratory flow - the maximum rate of drawing in O2 normally is 20L/min (not normally measured unless ITU) O2 therapy goal is increasing conc grad between alveoli and blood - done by increasing FiO2 (fraction of inspired O2) Devices types: * Variable (can't guarantee FiO2, depends on PIF): * Nasal cannula 1-4L * Hudson mask 5-10L * Non-rebreather mask 15L * Fixed: venturi mask (useful if COPD as need to know exactly how much O2 giving) - 24%, 28%, 35%, 40%, 60% **NOTE: If PIF increases (breathing harder) --\> FiO2 decreases so more device O2 is required** High-flow nasal oxygen therapy - humidifies + warms O2 = well-tolerated --\> very high flow rate can be achieved - finely controlled FiO2

Answer 124

Methotrexate --\> BM suppression & pancytopenia

Answer 125

Insulin: * High level of insulin --\> reduces serum BM (pushes into surrounding tissues & hepatic glucose store) * Low level of insulin --\> switches off ketone production Pathophysiology: * HHS = complication of T2DM * In HHS have enough insulin to switch of ketone production but not enough to reduce BM lvls * High glucose - osmotically active --\> polyuria --\> dehydration HHS criteria: * Hypovolaemia * Glucose \>30mmol/L * NO ketonaemia * Serum osmolality \>320mOsmol/kg Mx: REHYDRATE = **IV 0.9% NaCl (3-6L by 12hrs, deficit 110-220mL/kg)** * Targets: * Reduce **Na** by less than _10mmol/L/day_ (otherwise risk osmotic demyelination syndrome) * Reduce **BM** by over _5mmol/L/hr_ * NOTE: if targets not met by 0.9% saline --\> 0.45% instead * If fluid alone are not enough --\> **0.05 units/kg/hr fixed-rate insulin infusion**

Answer 126

Search - Surgery and long-term medication Anticoagulants/Platelets (several days before surgery) * Warfarin * Heparins - dalteparin * Antiplatelets - aspirin, clopidogrel, ticlopidine, dipyridamole * NSAIDs

Answer 127

1. Chlordiazepoxide (decreasing regimen + PRN) - prevent alcohol withdrawal Sx (anxiety, shakes etc.) + **_CIWA scoring_** (dose increased inf CIWA score increases) 2. Pabrinex (thiamine, B1) - prevent Wernicke's encephalopathy (ophthalmoplegia, ataxia, confusion) 3. Bloods - coagulation (injury, bleeds), LFTs

Answer 128

Stop Warfarin 5 days before Give Vit K (phytomenadione) 1-5mg PO

Answer 129

Furosemide: * 2 days - Weight * Longer - ejection fraction ACEi: improved exercise tolerance

Answer 130

Oral anticoagulants Parenteral anticoagulants

Answer 131

**Acute dystonia** - onset in hrs, spasms/muscle contractions (involuntary, painful, sustained) e.g. torticollis, oculogyric crisis (twists up, can't look down) * Tx: anticholinergic e.g. procyclidine IM/IV **Akathisia** - onset in hrs-wks, subjective psychomotor restlessness * Tx: propranolol ± benzo (cyproheptadine) **Parkinsonism** - onset days-wks, triad: resting tremor, bradykinesia, rigidity * Tx: anticholinergic e.g. procyclidine IM/IV **Tardive dyskinesia** - onset months-yrs, rhythmic involuntary mov of mouth, face, limbs, trunk (e.g. grimace, chewing, sucking mov) * Tx: stop antipsychotic/reduce dose, can try tetrabenazine **Neuroleptic malignant syndrome (NMS)** - onset days-wks, life-threatening, cog changes, fever, rigidity & bradyreflexia, autonomic dysfunction * Raised CK on bloods * Mx: stop antipsychotic, ITU, bromocriptine * NOTE: Serotonin syndrome has a similar presentation but acute (24hrs) & hyperreflexia, tremor, clonus, Tx with supportive care & benzo (cyproheptadine)

Answer 132

Amitryptiline (other 1st line options - pregabalin/gabapentin/duloxetine)

Answer 133

**K ABCD** **HTN**: * **K**+ sparing diuretics * **A**CEi/ARB, **B**-blockers (if renal dusfunct/insulin def), **C**alcineurin inh (Cyclosporine, Tacrolimus), **D**igoxin overdose * **H**eparins, **T**rimethoprim, **N**SAIDs

Answer 134

β-blockers, thiazide diuretics, corticosteroids (e.g. pred) **ST**u**D** **PRANC AB** * **ST**eroids (CS, OCP), **D**iuretics (thiazides, loop) * **PR**otease inhibitors (end in 'vir' e.g. Ritonavir), **AN**ti-psychotics/epileptics (e.g. phenytoin), **C**alcineurin inhibitors (Cyclosporine/Tacrolimus) * **A**drenaline, **B**eta-blockers (don't cause hyperglycaemia but delay recovery in T1DM & blunt Sx perception)

Answer 135

_CCB_ e.g. amlodipine _NSAIDs_ e.g. naproxen _Pioglitazone_ (DM drug) Hormones e.g. CS (pred), oestrogen, progesterone, testosterone Beta-blockers

Answer 136

Thiopurine Methyltransferase (TPMT) - low levels of this enzyme require a lowered dose of azathioprine

Answer 137

Opioids, Benzos, Anticholinergics NSAIDs, CCB GA, alpha-adrenoceptor antagonists Alcohol

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