PSA notes

Question 1

thiazide diuretic MoA + SEs

Question 2

what monitoring is needed when starting or changing eplerenone or spironolactone

Answer 2

plasma-potassium levels

Question 3

why would you withhold ACEi or ARB in an unwell pt with limited intake of food and water

Answer 3

to reduce risk of AKI

Question 4

side effect of tacrolimus on electrolytes

Answer 4

hyperkalaemia

Question 5

what drugs do you suspend in suspected AKI

Answer 5

DAMN
allopurinol - accumulates in renal failure especially if dose >100mg daily

Question 6

UTI treatment in penicillin allergy AND renal impairment

Answer 6

opt for trimethoprim as nitro is CI in egfr <45.

Question 7

how do you manage a pt on warfarin pre-operatively

Answer 7

stop their warfarin 5 days prior and if the INR >1.5 the day before surgery, give phytomenadione [vit K] orally - the IV prep is given PO

Question 8

side effect of steroids

Answer 8

• endocrine
  impaired glucose regulation
  increased appetite/weight gain
  hirsutism
  hyperlipidaemia
  Cushing’s syndrome
  moon face
  buffalo hump
  striae
  musculoskeletal
  osteoporosis
  proximal myopathy
  avascular necrosis of the femoral head
  immunosuppression
  increased susceptibility to severe infection
  reactivation of tuberculosis
  psychiatric
  insomnia
  mania
  depression
  psychosis
  gastrointestinal
  peptic ulceration
  acute pancreatitis
  ophthalmic
  glaucoma
  cataracts
  suppression of growth in children
  intracranial hypertension
  neutrophilia

Question 9

side effect of chlorpromazine

Answer 9

galactorrhea

Question 10

Trimethoprim effect on kidneys (eGFR)

Answer 10

Trimethoprim can cause an isolated rise in creatinine. It competitively inhibits creatinine secretion from the renal tubules, and causing a false drop in eGFR because of this (eGFR is calculated based on creatinine).

Question 11

what drug shouldn’t be taken with a BB and why

Answer 11

diltiazem + verapamil - causes severe bradycardia +/ or complete heart block [AV block]

Question 12

Maintenance fluid requirements for adults

Answer 12

• Water: 25 to 30 mL/kg
• K+, Na+, Cl-: 1 mmol/kg
• Glucose: 50 to 100g - limits starvation ketosis but not enough nutritionally.

Question 13

rate of administration of maintenance fluids

Answer 13

if able to meet requirements safely during the day: 6-10 hours
if pt is frailer, they will need a slower rate of administration and therefore may need overnight fluids t4: 12 hours minimum.

Question 14

Mx of a hypoglycaemic pt:
- in hospital
- in community/ public

Answer 14

• Glucose 20% 100ml over 15 minutes (10% also fine but 200ml).
• if conscious a fast releasing carb source orally - once BG levels come up, give a longer acting carb
• if drowsy / reduced consciusness, give the pt oral glucose gel applied bucally [NO food or drink]
• if unconscious, seizing or unable to swallow - 1mg IM glucagon to the thigh.

Question 15

Mx of hypokalaemia

Answer 15

• replaced via premixed K+ NaCL fluid bag
• 0.3% = 40mmol
• 0.15 = 20mmol
• requirement = 1mmol/kg/24 hours
• Fastest rate to replace =10mmol/hr on the ward (any faster requires cardiac monitoring).
  
  • So 0.3% minimum rate = 4 hours
  • 0.15% minimum rate = 2hrs

Question 16

hypercalcaemia presentation

Answer 16

• Stones, bones, abdominal groans and psychiatric moans
• ## ECG: shortened QT + bradycardia –> heart block

Question 17

Mx of hypercalcaemia

Answer 17

• When >2.6 mmol/l
• agressive rehydration, can consider IV bisphosphonates later
• NaCl 0.9% 1000ml over 4 hours - give ~4-6L in total.

Question 18

HRT regimens

Answer 18

Uterus or no?
- uterus => combined oestrogen + progesterone to protect the uterus from endo cancer
- no uterus => oestrogen only HRT

pre menopausal or post-menopausal [with a uterus]
- women still having periods => cyclical progesterone to allow a bleed
- >24 months without a period if under 50 years
- >12 months without a period if over 50 years
- no periods => continuous progesterone

Formulation
- oral tablet
- transdermal [patch, cream]
- Patches are more suitable for women with poor control on oral treatment, higher risk of venous thromboembolism, cardiovascular disease and headaches. [patches carry a lower risk of VTE]

Question 19

indications for HRT

Answer 19

• Replacing hormones in premature ovarian insufficiency, even without symptoms
• Reducing vasomotor symptoms such as hot flushes and night sweats
• Improving symptoms such as low mood, decreased libido, poor sleep and joint pain
• Reducing risk of osteoporosis in women under 60 years

Question 20

HRT CIs

Answer 20

• Undiagnosed abnormal bleeding
• Endometrial hyperplasia or cancer
• Breast cancer
• Uncontrolled hypertension
• Venous thromboembolism
• Liver disease
• Active angina or myocardial infarction
• Pregnancy

Question 21

how to choose a HRT regimen

Answer 21

Step 1: Do they have local or systemic symptoms?

• Local symptoms: use topical treatments such as topical oestrogen cream or tablets
• Systemic symptoms: use systemic treatment – go to step 2

Step 2: Does the woman have a uterus?

• No uterus: use continuous oestrogen-only HRT
• Has uterus: add progesterone (combined HRT) – go to step 3

Step 3: Have they had a period in the past 12 months?

• Perimenopausal: give cyclical combined HRT
• Postmenopausal (more than 12 months since last period): give continuous combined HRT

Question 22

HRT pills and patches

Answer 22

• pills = elleste [solo or duet ± conti]
• patches = evorel [solo or sequi

Question 23

contraception regimens

Answer 23

combined
- microgynon 30 (ethinylestradiol with levonorgestrel)

POP
- cerazette (desogestrel)

Question 24

HRT and contraception options

Answer 24

HRT ≠ contraception t4 contraception is needed for perimenopausal women:
- POP in addition to HRT
- mirena coil

Question 25

what contraceptives can and cant be used post birth

Answer 25

- avoid COCP in breastfeeding mums for minimum 6 weeks post partum - POP + implant are considered safe in breastfeeding and can be started at any time after birth - copper and mirena coils can be inserted either within 48 hours of birth or more than 4 weeks after birth (UKMEC 1), but not inserted between 48 hours and 4 weeks of birth (UKMEC 3). - **Lactational amenorrhea** is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).

Question 26

missed pill rules: POP

Answer 26

missed = - > 3hours late for trad POP [norethisterone + levornogestrel] - >12 hours for desogestrel. - Episodes of diarrhoea or vomiting are managed as “missed pills”, and extra contraception (i.e. condoms) is required until 48 hours after the diarrhoea and vomiting settle. rules = - take the missed pill ASAP [can take 2 within 24 hours / together if needed] - return to normal use and use barrier methods for 48 hours - if UPSI happens within this time [missed pill - 48 hours of regular use] => emergency contraception

Question 27

missed pill rules COCP

Answer 27

**missed** = - >24 hours late for next pill [no pill taken for 48 hours] **rules** *missing 1 pill [ < 72 hours without pill]* - Take the missed pill as soon as possible (even if this means taking two pills on the same day) - No extra protection is required provided other pills before and after are taken correctly *missing > 1 pill [>72 hours without pill]* * Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day) * Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight * If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex * If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required * If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period ## Footnote REMEMBER theoretically women will be protected if they perfectly take the pill in a cycle of 7 days on, 7 days off. This will prevent ovulation

Question 28

T2DM Mx

Answer 28

1. Metformin = 1st line - Add SGLT-2 inhibitor if patient has existing CVD or HF, or if high QRISK 1. 2nd line: add sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor 1. 3rd line: triple therapy with metformin and two of the other second line drugs, or insulin therapy

Question 29

key monitoring for metformin

Answer 29

eGFR (due to the risk of lactic acidosis if eGFR drops too low).

Question 30

what do you do if a pt on metformin needs an MRI with contrast

Answer 30

hold the metformin due to risk of AKI when used with contrast

Question 31

1st line mx for post op N+V

Answer 31

ondansetron

Question 32

opioid pain management in pts with renal impairment

Answer 32

opt for oxycodone as it is metabolised into the inactive form by the liver where as morphine is metabolised into a more potent form morphine AND is also renally excreted => buildup and toxicity

Question 33

triptans are not suitable for who?

Answer 33

pts with HTN

Question 34

resus fluids for a child

Answer 34

- 0.9% NaCl - weight x10 - over 10 mins

Question 35

synonym for hypotension/ postural hypotension

Answer 35

hypovolaemia

Question 36

synonym for reduced appetite

Answer 36

anorexia

Question 37

threshold for medical Mx of gestational diabetes

Answer 37

>7mmol fasted blood glucose

Question 38

tricyclic antidepressant overdose features

Answer 38

- Tri - QRS complex wide - cyclic - big round pupils - [A] - arrhythmias - ventricular tachy or fibrilation

Question 39

# ss drugs that may affect seizure control in epilepsy

Answer 39

* alcohol, cocaine, amphetamines * ciprofloxacin, levofloxacin * aminophylline, theophylline * bupropion * methylphenidate (used in ADHD) * mefenamic acid