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Flashcards in CPTP4 Deck (306):
1

define adverse drug reaction

any response to a drug which is noxious, unintended and occurs at doses used for prophylaxis, diagnosis or therapy

2

define medication error

any preventable event that may cause or lead to inappropriate medication use or patient harm

3

how does the human medicines regulations categories medical substance?

1. prescription- only medicines
- registered medical practitioners can do all
- midwives, nurses and pharmacists can do some
- patient group directions
2. pharmacy
- pharmacists can give
3. general sales list
- anyone

4

how are pharmacy medicines released from the POM category?

-must be appropriate to self diagnose
- small chance of causing harm
-no chance of dependence
- cant be parental or eye admin

5

what does 'controlled' mean in the context of medicines?

controlled under the Misuse of Drugs Act. they are categorized into class (how harmful is it?) and schedules

6

what 3 criteria could mean a substance becomes controlled?

misuse may result in psychological, physical or social harm

7

in the misuse of drugs act, what does the schedule determine?

requirements for wholesale, storage, prescription etc.
schedule 1: no medical use
cant have/ use without a licence e.g. cannabis
schedule 2: medical use
controlled drug prescription and special arrangement for storage e.g. diamorphine

8

what is a named patient drug?

a drug that might have been discontinued from marketing regulations etc. but you can keep prescribing it for a person who's been on it for a long time

9

what extra information must you put when prescribing a controlled substance?

total quantity in both words and figures

10

define tolerance

high dose required to achieve same response

11

physical dependence

develops when neurons adapt to repeated drug exposure and only function normally in the presence of the drug. therefore withdrawal precipitates unpleasant physiological effects

12

psychological dependence

emotional need for a drug that has no underlying physical need

13

what is the %UK lifetime prevalence of drug misuse?

35%

14

how many deaths are there in the UK per year as a result of drug misuse? population distribution?

~2000
males >females
highest in 35-44 yo
NE england highest

15

which illegal drugs are responsible for the most deaths in the UK?

opioids

16

define therapeutic drug monitoring

individualisation of dosage by maintaining plasma/ blood drug concentration within a target range

17

3 ways therapeutic drug monitoring is carried out and examples.

1. monitoring plasma/ blood drug conc.
2. measuring clinical response (e.g. how much angina)
3. measuring the pharmacodynamic effect (e.g. effect of insulin on blood glucose)

18

why should gentamicin be closely monitored?

narrow therapeutic window : ototoxicity and nephrotoxicity

19

three examples of drugs that indicate monitoring of plasma drug conc.?

digoxin
phenytoin (anti-epileptic)
gentamicin

20

what is the most common cause of iatrogenic disease?

adverse drug reactions (occur in 20% of hospital admissions)

21

3 adverse reactions to prednisolone?

hyperglycaemia
GI complications
OP

22

three example of augmented drug reactions?

insulin -> hypos
warfarin -> bleeding
nitrates -> headaches (vasodilation)

23

which drug is antagonistic to salbutamol?

B-blockers

24

how can antacids interact with other drugs?

decrease stomach acidity so more drug ionisation
this means it cannot be absorbed as fast
(the opposite is true for drugs that increase stomach acidity

25

muscarinic agents will have what effect on drug absorption? e.g.

decrease it due to increasing GI motility
bethanecol for urinary retention

26

what are the two types of allorecognition in transplants?

direct- donor APC migrates to regional lymph node and activates host t cells -> direct cytotoxic T cell response. seen in acute rejection
indirect- recipient APC processes peptides from dead cells from transplant organ. host t cells migrate to attack graft. fewer t cells are activated. seen in chronic

27

what does the suffix -mab mean in a drug?

that its a monoclonal antibody drug

28

define pharmacogenomics

use of genetic information to guide the choice of drug and dose on an individual

29

what is the effect of fast or slow acetylation on the metabolism of isoniazide?

fast- get lots of the hepatotoxic metabolite
slow- get a build of the drug which is neurotoxic

30

pathophysiology of PD

loss of dopaminergic cells in substantia nigra leads to degeneration of projections to other areas of basal ganglia

31

ways to intervene with dopamine levels

1. give L-dopa (MOST EFFECTIVE)
2. MAO-B
3. block degradation of D in synaptic cleft- COMT inhibitors
4. dopamine agonist

32

what must be given with l-dopa and why?

DDI- dopamine decarboxylase inhibitor
reduced sfx by stopping conversion of L-dopa into dopamine

33

long term side fx of l-dopa? which other drug does this?

dyskinesia- occurs in 50% of patients after 6 years

COMT inhibitors

34

which parkinsons medication can cause loss of impulse control?

dopamine agonists

35

which PD drug can cause seretonin syndrome?

MOA-B

36

which neurotransmitter dysregulation can cause epilepsy?

glutamate

37

epilepsy drugs i should know?

carbamazapine
sodium valproate
levetiracetam
phenytoin
lamotrigine

38

what are absence seizures treated with?

ethosuximdie (or sodium valproate)

39

tx for status epilepticus

1. Secure airway and give O2 – airway or intubate, cardiac monitoring, oximetry
IV access + bloods
Glucose ( rule out hypo) , thiamine ( alcohol is often a cause) , maintain AEDs

2. PR diazapam or buccal midazolam -> IV lorazapam -> phenytoin

3. if they don't respond to this then give IV phenytoin

40

what is the risk of giving IV phenytoin?

can cause hypotenision

41

what are the features of a parkinsons tremor?

5Hz
pill rolling
asymmetrical

42

what drug class is apomorphine?

dopamine agonist

43

what effect does the carbamazapine have on metabolism?

enzyme inducer therefore speeds metabolism

44

carbamazapine side fx

blurred vision
back and forth eye movement
drowsiness
nausea
rash
etc

45

drugs that induce parkinsons

dopamine antagnoinsts- neuroleptics and anti-emetics

46

when is a DAT scan helpful?

determine if there was pre-existing PD in someone with drug induced parkinsons

47

best initial Tx for drug induced PD?

co-benoldopa (l-dopa with decarboxylase inhibitor)

48

mechanism of metformin?

inhibits hepatic gluconeogenesis

49

sulphonylurease mechanism? and example

increase insulin secretion
gliclazide

50

sfx of sulphonylurease

hypos, weight gain

51

how do thiazolidinediones work?

increase lipogenesis
decrease lipolysis

(NOT USED MUCH NOW)

52

why is more insulin produced if sugar is ingested vs injected?

gut plays a role in hormone regulation

53

how do DPP-4 inhibitors decrease glucose?

prolong t1/2 of GLP-1 (which increases insulin secretion and decreases glucagon)

54

statins mechanism?

decrease cholesterol synthesis
increase uptake of cholesterol from blood to liver

55

two methods for calculating the anion gap?

Na + K - (HCO3 + CL) normal is 16+/-4
Na - (HCO3 + Cl) normal is 12+/-4

56

causes for high anion gap?

MUDPILES
methanol / metformin
ureamia
DKA
Paracetamol
Iron / isoniazide
Lactic acidosis
Ethanol
salicylate

57

why is there raised blood glucose in DKA / HHS?

absolute or relative insulin deficiency stimulates hepatic glucose production
this cannot get into the cells

58

criteria for diagnosing DKA?

ketones- in urine or blood
glucose > 11mmol/L (or known diabetic)
bicarb <15mmol/L OR acidosis

59

what initial fluid do you give in DKA?

0.9% saline
w/o K+ at first then give it after the first bolus
the first one needs to be given very quickly so isn't safe to give K

60

potassium levels in DKA and why?

serum potassium high as trying to get rid of H+ ions in the urine (potassium / hydrogen pump)

61

in what way is acidosis good in DKA?

improves O2 delivery to tissue by shifting saturation curve to the right

62

insulin therapy in DKA? what to do if this is delayed?

fixed rate IV insulin infusion
IM infusion

63

in DKA what should be monitored continuously?

-Hourly capillary blood glucose
-Hourly capillary ketone measurement
-Venous bicarbonate and potassium at 60 minutes, 2 hours and 2 hourly thereafter
-4 hourly plasma electrolytes
-Continuous cardiac monitoring if required
-Continuous pulse oximetry if required

64

after DKA what is the most reliable way of measuring ketone level?

blood ketones
urine ketones will still be present for a while

65

in DKA, what should the overlap be in previous insulin regime and infusion?

infusion maintained until 30 mins after SC insulin

66

initial response to hypos

ABC
give 80ml 20% glucose IV
1mg of glucagon IM (to mobiles glucose from the liver)
repeat BM:
-if < 4 then repeat glucose
-if >4 then give long acting CHO once recovered

67

what should a diabetic woman trying for a child take?

5mg folic acid unitl 12 wks

68

during delivery, what should a diabetic woman be given?

GKI infusion

69

two side effects of statins?

rhabdomyalisis / myositis
raised transaminases

70

whys that liver disease alters response to drug?

Impaired drug metabolism - more will be in circulation
Hypoproteinemia
Reduced clotting
Hepatic encephalopathy
Fluid overload - abnormal Na handling
Hepatotoxic drugs

71

how can hepatic disease effect pharmacokinetic?

either causes drug accumulation or failure to form an active / inactive metabolite
Increased bioavailability after oral administration
Alteration in drug protein binding, and kidney function.

72

3 factors that determine drug elimination by the liver

1. blood flow (Q) throught the liver

2. The fraction of drug (f) in the blood that is free or unbound to plasma proteins and capable of interacting with hepatic enzymes

3. Intrinsic clearance (Clint) is the intrinsic ability of the liver to metabolize drug in the absence of flow limitations and binding to cells or proteins in the blood.

73

what is the extraction ratio?

The fraction of the drug removed from the perfusing blood during its passage through the organ
i.e. Drugs with high hepatic ER have a large first-pass effect, therefore low oral bioavailability.

74

if the extraction ratio of a drug is 0.4, what is the bioavailability?

0.6

75

why avoid sedative, diuretics and drugs that cause constipation in LD?

precipitates encephalopathy

76

what regulates the secretion of H+ in the stomach?

gastrin

77

drug induced dyspepsia

NSAIDs – gastritis and peptic ulcers
Steroids – gastritis and peptic ulcers
Calcium antagonists - gastritis
Nitrates - Reflux
Theophyllines - gastritis
Bisphosphonates – oesphageal erosion and ulceration.

78

epigastric pain relation to meals?

GU – worse with / shortly after meals
DU – relieved during meals, worse 2-3h after meals or at night

79

ways to test for H pylori

Faecal antigen test
Carbon 13 urea breath test
Serum H.pylori antibody test
Endoscopic biopsy samples – rapid urease test

80

sfx of ant acids

constipation- the Al ones
diarrhoea - the Mg ones

81

first line treatment of peptic ulcer disease and GORD

H2r antagonists

82

how do PPIs work? 2 examples

PPIs cause irreversible inhibition of H+/K+ ATPase responsible for H+ secretion from parietal cells

omeprazole, lansoprazole

83

H2r antagonists mech of action

H2 receptor antagonists competitively block the action of histamine on the parietal cell by antagonising the H2 receptor

84

what is triple therapy for H. pylori?

PPI, amoxicillin and clarithromycin OR
PPI, amoxicillin and metronidazole

85

4 types of laxatives and their mech?

1. Bulk forming - Increase volume of non- absorbable material in the gut therefore distending the colon and increasing peristalsis

2. Osmotic - Increase water content in the bowl via osmosis therefore distending the colon and increasing peristalsis

3. Stimulant - Increase gastrointestinal peristalsis

4. Faecal softeners - Promote defecation by softening /or lubricating the stool

86

contraincations for bran / hisk / methylcellulose?

dysphagia
obstruction
faecal impaction
clonic atony

87

in liver disease, how should the dose of an oral drug with a high extraction be changed?

reduced initial dose
reduced maintenance dose

all undergoing less first pass metabolism so will have higher bioavailablity

88

in liver disease, how should the dose of an IV drug with a high extraction be changed?

normal initial dose
reduced maintenance dose

the initial dose will not undergo first pass metabolism via the portal vein as it isnt in the GI system
however eventually it will go through the liver and be metabolised so maintenance should be less

89

how to work out reduced dose for liver disease patients

Reduced dose = (normal dose X bioavailability)/100

normal dose is the dose in a patient without LD
bioavailability is drugs availability in a healthy person

90

what counts as a high extraction ratio?

>_0.7

91

what is the CLO test for and how does it work?

diagnosing H. pylori AKA rapid urease test
biopsy of mucous from the lining of the stomach, h. pylori produces urease that converts urea to ammonia hence changing the pH of your solution

92

which abx for H pylori?

amoxicillin + (clarithromycin OR metronidazole)

93

diagnosis of a perforated PUD?

adbo x-ray : can see air under the diaphragm

94

what drug class is loperamide hydrochloride?

anti-motility
acts on opioid receptor

95

what is the mx pathway for suspected gastric cancer?

lifestyle changes and URGENT endoscopy
must be off PPIs for at least 2 weeks for endoscopy

96

if H pylori positive, how long do you continue the PPI for in eradication therapy ?

2 months

97

problems with PPIs?

low mg
risk of C diff
actue intertial nephritis (rare but this is a common cause of it)
microscopic colitis

98

why doesnt loperamide cause euphoria?

cant cross BBB

99

how does loperamide reduce diarrhoea?

binds to opioid receptors to decrease peristalisis

100

constipation red flags

Weight loss

Unexplained microcytic anaemia

New onset constipation in an elderly patient

101

in dyspepsia who should be referred for urgent endoscopy?

new onset AND over 55

102

Mx for dyspepsia in the U55s

'test and treat'
test for H pylori : urea breath test or stool antigen
4 weeks full dose PPI

103

response to a meal in duodenal ulcers and why?

initially eases pain then gets bad again
the pyloric sphincter closes therefore the acid cannot reach the duodenum. about 2-3 hours later the sphincter opens

104

Mx for symptoms of an upper gastrointestinal bleed?

ABC
urgent endoscopy + therapy
inform ITU and surgeons

105

what is the endoscopic therapy for UGIB? and what else do you give?

adrenaline injections
haemospray
clips
heat probe
argon- plasma coagulation

IV PPIs

106

when to give PPIs in UGIB?

only after confirmation by endoscopy

107

two reasons to do another endoscopy 8 weeks after UGIB?

check healing
?cancer

108

effect of NSAIDS on the kidneys?

cause afferent renal arteriol vasoconstriction

109

contraindications for opioid anti-motility drugs

Severe ulcerative colitis or C.diff – increases the risk of Toxic megacolon
Severe infective diarrhoea
Dysentery (bloody stool)
Liver disease (risk of accumulation)

110

indications for opioid anti-motility drugs

- mild infective diarrhoea
- irritable bowel syndrome
- chronic IBD diarrhoea
- high output stomas

111

which types of laxatives are avoided if there is suspected obstruction?

stimulant
bilk forming

112

indications for investigating constipation?

>40yrs
Recent change in bowel habit
Iron deficiency anaemia
Assoc symptoms (weight loss, rectal bleeding, mucous discharge or tenesmus)

mostly it doesnt need investigating

113

difference between SABA and LABA?

LABAs are chemical analogues of salbutamol with a long lipophilic side chain anchors the drug in the lipid membrane therefore:
the active portion of the molecule to remain at the receptor site

114

electrolyte abnormality caused by B2 agonists?

hypOkalaemia

they are sometimes used to treat hypERkalaemia

115

what drug class is ipatropium?

SAMA

116

what drug class is tiotropium?

LAMA

117

which patients cant tolerate adrenergic agonists e.g. B2 agonists?

ischaemic heart disease or tachycardia

118

Theophylline use and mech of action?

second line therapy in asthma

Inhibits phosphodiesterase to cause an increase in cAMP in smooth muscle cells

119

use of leukotriene receptor antagonists and example

prohylaxsis for asthma NOT symptom relief
montelukast

120

two main adverse effects of corticosteroids in asthma

horse voice
oral candidiasis

121

what oral corticosteroid is used in asthma?

prednisalone

122

what is the first line regular preventer?

low dose ICS

123

if low dose ICS is not controlling asthma what is added next?

LABA

124

drugs that can exacerbate asthma?

B-blockers -> bronchospasm (esp. non-selective e.g. propranolol)
NSAIDS -> bronchospams (aspirin sensitivity affects 20%

125

how much of an inhaled drug ends up in the lungs?

10%

126

why are there systemic side effects when drugs are inhaled?

90% is swallowed

127

Mx of acute asthma

O2
steroids
B2 agonists
IV mg sulphate
ipatropium bromide

128

Mx of COPD exacernation

Oxygen (high flow O2 can be dangerous in type 2 resp. failure)

Oral Steroids (Short course)
Antibiotics (Simple (amox.) and Short)

Nebulised Bronchodilators
NIV (non-invasive ventilation)

129

what increase in peak flow post SABA indicates asthma?

200ml

130

theophylline mech and use?

raises intracellular cAMP which promotes smooth muscle relaxation

used in asthma

131

alternative for B blockers in asthmatic patients?

prostaglandins

132

abx for CAP?

amox
clarithromycin
doxycycline (this is used if someone with COPD is hospitalised as it covers the more obscure pathogens)

133

Tx for exacerbation of COPD?

salbutamol and ipratropium NEB
?O2
prednisalone (oral)

134

name a leukotriene receptor antagonist used in asthma

montekeukast

135

3 ICS used in asthma?

beclamethosome
budensoide
fluticasone

136

interaction between glaucoma and asthma tx?

topical b-blocker used in glaucoma can have systemic effects of bronchospasm

137

define acute severe asthma and when should you admit?

PEF 33-50% best or predicted
respiratory rate ≥25/min
heart rate ≥110/min
inability to complete sentences in one breath

admit if symptoms persist after initial tx

138

two drug classes that exacerbate asthma and alternatives?

NSAIDS
- only avoid if you know it worsens your asthma
- aspirin sensitivity in 20%, use clopidogrel

B-blockers
-use prostaglandin analogue instead

139

what does a rising PaCO2 tell you about a patient in an asthma attack?

they are getting exhausted and failing to blow off CO2- BAD

140

Mx for acute severe asthma

O2
Neb : salbutamol and ipratropium
steroids

141

what to consider in mx of pneumonia in asthmatic patient

are they on theophylline - this is INHIBITED by clarithromycin and ciprofloxacin

142

theophylline mech?

Competitive nonselective phosphodiesterase inhibitor
- reveres steroid insensitivity
- reduces inflammation and innate immunity

143

what is carbocistenine

mucolytic

144

on an ABG which values tell you weather the problem is acute or chronic?

deranged pH means it's a chronic problem - cant live with that for long
bicarb. - takes a while to change

145

type 1 resp failure is due to what

V/Q mismatch i.e. the alveolar are well ventilated but O2 is not getting into the blood
e.g.
- O2 cant get to capillaries (seen in pneumonia)
- blood cant get to alveolar (seen in PE)

146

type 2 resp failure is due to what

ventilatory failure
e.g.
obstructive disease
emphysema

147

when to give LTOT?

PaO2 < 7.3
OR
PaO2 7.3 - 8 AND cor pulmonale

148

what information is needed and how to calculate 'no. needed to treat'

risk without treatment over 10 yrs
risk with treatment over 10 yrs

the difference between these two is the ABSOLUTE RSIK REDUCTION (ARR)

NNT = 100 / ARR

therefore you need to treat x number of people over 10 years to save 1 'event'

149

what are ABPM and HBPM and whats the point in them?

ambulatory/ home BP monitoring
average BP over 24hrs.
HBPM- have to measure your own BP
ABPM- does it for you several times a day

to eliminate white coat hypertension

150

define the stages of hypertension

stage 1
- >140 / 90 OR
- >135/85 AVERAGE if ABPM or HBPM

stage 2
- >160 / 100 OR
- >150 / 95 AVERAGE if ABPM or HBPM

severe
- >180 / 110

151

when to treat hypertension?

stage 1 IF THEY HAVE A RAISED CV RISK (QRISK or other)
stage 2 always

152

5 classes of drugs used in hypertension

ACE inhibitors
CCBs
Diuretics
A2RB
cardiac glycosides

153

Mx of hypertension in pregnancy?

use labetolol

154

what QRISK score warrants a statin?

>10% risk of CVD

155

what U&E's would be expected in someone not tolerating ARBs?

raised Na
low K

156

acute heart failure Mx?

IV furosemide
O2
sit up right

157

what is the ejection fraction and what is normal?

amount of blood squeezed out of ventricles
>55%

158

what are the 4 steps of anti-hypertensive treatment?

step 1
A* (if under 55) or C (if over 55 or black)

step 2
add A or C in

step 3
add in thiazide like diuretic

step 4 (resistant hypertension)
further diuretic OR alpha blocker OR beta blocker

*ACE inhibitor OR A2RB

159

two safe antihypertensive treatments in pregnancy

methyldopa
nifedipine

160

how to calculate absolute risk reduction?

risk without treatment - risk with treatment

161

first line tx for acute heart failure?

Sit patient up, give high flow oxygen, iv access
Furosemide 40-120mg i.v. (lower dose with diuretic naïve patient)
(do not offer diamorphine or nitrates)

162

5 chronic heart failure drugs?

ACE I
A2RB
B blockers
furosemide
digoxin
spironolactone

163

adverse effects of HF treatment?

Loop diuretics
urinary frequency, hypokalaemia, volume depletion, renal impairment, gout, urinary retention
ACEI
cough, renal impairment, hyperkalaemia, hypotension, angioedema
Angiotensin antagonists
renal impairment, hyperkalaemia, hypotension
BBs
bradyarrhythmias, cold extremities, bronchospasm, fatigue, worsening HF, intermittent claudication
Spironolactone
hyperkalaemia, gynaecomastia
Digoxin
dig toxicity - nausea, vomiting, abdo pain, confusion, brady and tachyarrhythmias

164

which HF drugs cause hypERkalaemia? and which hypO?

hyper:
ACE I
angiotensin antagonists
spironolactone

hypo:
furosemide

165

what is metoclopramide?

increase smooth muscle activity
also used as anti emetic

166

what is buscopan?

Hyoscine butylbromide- treats colicky abdo pain

167

WHO analgaesia ladder

strong opioid + non-opoiod

weak opioid

non-opioid

168

3 examples of weak opioids

tramodol
codeine
dihydrocodeine

169

what is the preferred method of delivery for pain relief and why?

oral - can be done at home

170

if you doubt someones pain (suspect they are after drugs) what should you do?

treat them regardless at first

171

what is 'step 4'?

new (since the 80's) pain management :
epidural , nerve block, spinal stimulation

172

what is the max. paracetamol dose?

4g / day

173

can you give paracetamol to someone with liver failure?

can give 1 - 3 g per day without increased incident of decompensation

174

NSAIDS mech of action?

block COX -> decreased prostaglandin synthesis

175

what do COX 1 and 2 do?

COX 1 is involved in normal physiological function e.g. protecting gastric mucosa , platelet aggregation

COX2 involved in pain and inflammation

176

why do we not use COX 2 selective NSAIDS so much as ones more selective for COX1?

even though COX 2 are better for pain / inflammation they have been shown to increase CV events

177

NSAID contraindications

GI symptoms / peptic ulcer disease

Liver or renal impairment

Asthmatic with aspirin sensitivity

Coagulation disorders/treatment

178

can you give NSAIDS in a patient with cardiac failure?

yes, with caution

179

mech of action of codeine?

Converted to morphine by CYP2D6

180

what must always be given with codeine?

regular laxatives

181

when is tramadol favoured over codeine and why?

bowel surgery - less constipating

182

adverse of effects of tramadol?

confusion in the elderly

183

contraindications of tramadol?

Severe renal / hepatic failure
Raised intra-cranial pressure
Severe respiratory depression

184

morphine mech of action?

Acts on µ-opioid receptors in the CNS

185

features of opioid toxicity?

myoclonic jerks,
pin-point pupils,
hallucinations,
confusion,
reduced RR.

186

when to give Naloxone in morphine OD?

difficult to rouse,
RR<8 and/or saturations<90%
(slow titration if on opiates for pain)

187

when are bisphosphonates used to manage pain?

bone pain - reduces turn over

188

when is buscopan used in pain management and how does it work?

reduce pain in constipation - anti muscarinic so less smooth muscle contraction

189

5 things we prescribe for at end of life

pain
breathlessness
N&V
excess secretions
agitation

190

what to give in renal impairment instead of morphine at end of life?

alfentanil if eGFR<30

191

drug to give in end of life care for N&V and an alternative for renally impaired?

cyclizine
haliperidol

192

drug for agitation at end of life?

midazolam

193

drug for excess secretions at end of life?

Hyoscine Hydrobromide - normally used as motion sickness drug

194

what is hyoscine butylbromide and when is it used? advantages?

anti motility used to reduce secretions in end of life care.
used when eGFR < 30
doesnt cross BBB therefore no drowsiness

195

disadvantage of hyosine hydrobromide?

if it builds up it crosses the BBB and causes drowsiness

196

what analgesia is provided for post op hip fracture

morphine and paracetamol

197

what is a PCA machine?

patient controlled analgesia

198

define dyasthesia

unpleasant sensation when touched due to peripheral nerve damage

199

tx for neuropathic pain

amitryptaline, duloxatine, gabapentin/ pregabalin

200

why avoid oral drugs in hip fractures?

want them to be nil by mouth for surgery

201

define allodynia

pain in response to a non-painful stimuli

202

how long do TCAs take to reduce neuropathic pain?

2 weeks

203

when to take TCAs and why?

at night due to sedating effect

204

difference between TCAs and SSRIs/SNRIs for pain?

TCAs work faster and is MORE effective

205

what is the most you should increase a dose of morphine in 24 hours?

50%

206

what is the ratio of oral to s/c morphine?

2:1

207

if someone is on 100 mg of oral morphine and you want to switch it to s/c, how much do you give?

50 mg

208

define bacteriostatic

stops bacteria multiplying

209

5 areas to kill a bacterium

cell membrane
cell wall

210

what is fluclox effective against?

gram + only

best thing for staph. aureus

211

what is amoxicillin effective against?

some gram + and some gram -

212

what is cefalexin good at penetrating?

skin and urine

213

what is metronidazole good against?

Anaerobic organisms, protozoa

214

how does metronidazole work?

Destroys bacterial DNA by forming toxic metabolites

215

S/E of metronidazole?

disulfiram reaction with ethanol

CANNOT DRINK ON THIS

216

how do macrolides work?

Inhibit protein synthesis by inhibiting binding at 50S ribosomal subunit

217

which -mycin is NOT a macrolide?

clindamycin

218

how does clindamycin work?

Inhibit protein synthesis by same mechanism as macrolides

219

how do tetracyclines work?

Bacteriostatic : Inhibit protein synthesis by inhibiting binding of tRNA to 30S ribosomal subunit

220

who cant have tetracyclines?

children (stains teeth)
and pregnant women - same reason

221

three S/Es of tetracyclines

GI
sun sensitivity
hepatotoxic

222

how do aminoglycosides work and an example?

Inhibit protein synthesis by inhibiting binding at ribosome (both subunits)

gentomicin

223

S/E of aminoglycosides

Nephrotoxic, ototoxic (tinnitus)

224

most important quinolone?

ciprofloxacin

225

how does ciprofloxacin work?

Inhibit DNA gyrase which coils DNA

226

S/E of ciprofloxacin?

GI - associated with c. diff

227

how does trimethprim work?

Inhibit DNA synthesis by folate inhibition

228

why is nitrofurantoin only used for UTIs?

Active concentrations only in urine

229

why dont you use nitrofurantoin in renal failure?

wouldnt get high enough concentrations in urine

230

how long after initial tx should abx be reviewed?

48 hrs

231

which abx are always monitored?

vancomycin
gentamycin (and other aminoglycosides)

232

s/e of gentamycin

ototoxic and nephrotoxic

233

fever + new mummer diagnosis?

IE

234

most common pathogens for IE?

staph and strep

235

abx for IE?

fluclox and gentamycin

236

define paroxysmal AF

2 or more episodes less than 48 hours duration

237

what pre disposes a young person to AF

WPWS
hyperthyroidism
alcohol / drugs
congenital heart disease
valvular disease

238

how does the duration of AF effect how you cardio vert them?

always try drugs first
if more than 48hrs you CANNOT shock them due to risk of emboli
must anti coagulate for 2-3 weeks then bring them back

239

what Ix would you following AF

bloods
- infection
- TFTs
- U&Es

24 hr ECG

ECHO

240

what are the options for initiating warfarin? why?

RAPID loading - give tinsaparin

in the first 24 hours warfarin will make your blood more coagulable because it uses up protein C and protein F

SLOW loading

241

what is the target inr for AF patient?

2-3

242

which rugs MUST be avoided in warfarin patients

ibuprofen
aspirin

243

which foods must be avoided in warfarin patients?

vit. K high foods e.g. grapefruits

244

what is given to reverse warfarin?

if very high (over 5 / 6 ) give vit K
even higher give it IV

if just a little high just omit a dose

245

2 most common organisms to cause cellulitis?

staph A
beta haemolytic strep

246

what abx is used initially in cellulitis?

IV fluclox
consider oral switch after a few days

247

good alternative to fluclox in cellulitis?

clindamycin

248

which drug is most suitable for cardioverting acute onset AF?

flecainide
amiodarone

249

in structural heart disease which drug is most suitable for cardioverting acute onset AF?

amiodarone

250

what is the most common side effect of IV amiodarone?

hypotension

also can cause thrombophlebitis if not given by central line

251

when do you need to anti-coagulate a patient before electrical cardioversion?

if they've been in AF for more than 48 hrs

252

in paroxysmal AF which type of control do you need?

rhythm (B-blocker or amiodarone)

rate control is useless as mot of the time they are fine

253

when does a person in AF need rate control?

if >89bpm

254

first line rate control drug in paroxysmal AF? if there is a contraindication?

B blocker
amioderone

255

what is the relative risk reduction of using warfarin?

2/3s

256

what are the contraindications for electrical cardioversion?

anything that makes recurrence likely

257

target for INR in AF?

2-3

258

effect of grapefruit juice on drugs?

enzyme inhibitor

259

in a serious / life threatening bleed in a warfarin user, what is the mx?

IV vit K
Beriplex (pro-thrombin complex)

could also use fresh frozen plasma as this has all the clotting factors in

260

how does erythromycin interact with other drugs?

it is an enzyme inhibitor therefore enhances them

261

first line rate control drug in persistent AF? if there is a contraindication?

blocker
CCB e.g. verapamil

262

why is AF bad

get stasis in the L atria
decreased CO -> tiredness

263

most common causes of AF?

cardiac:
IHD, RHD, htn

non- cardiac:
thyrotoxicosis, infection

264

how is amiodarone used in the management of AF?

for rhythm control but only short term

265

what are the chronic adverse effects of B blockers?

fatigue
peptic ulcer disease

266

which CCBs can you NOT use in AF? why?

dihydropyridines e.g. amlodapine, nifedipine

these have more effect on relaxing blood vessels than on relaxing heart muscle

267

who is digoxin NOT used in?

active people

268

how does digoxin work?

increase intra cellular Ca++ and vagal tone

269

what are the chronic effects of amiodarone ?

photo sensitivity
thyroid dysfunction

270

what are the types of DOAC and how do they work?

factor Xa inhibitors e.g. rivaroxaban , apixaban
direct thrombin inhibitors e.g. dabigatran

271

warfarin mech?

vit K antagonist

272

what organism is most commonly implicated in fever + purpuric rash?

Neisseria meningitidis

273

what abx is used for meningococcal septicaemia

IV ceftriaxone

274

what is given as well as abx in meningitis ?

steroids to reduce complications

275

how are contacts of menigococcal meningitis managed?

contact public health -> give rifampicin / ciprofloaxacin

276

most common pathogen in bac. endocarditis?

native valve- strep viridans
prosthetic valve - staph aureus

277

what combination of abx is used to treat bac endocarditis in a person with their own valves?

benzyl penicillin & gentamycin

278

what combination of abx is used to treat bac endocarditis in a person with prosthetic valves?

fluclox & rifampicin

279

when do ex bac. endocarditis patients get prophylaxis? what is it

only in invasive procedures
amox

280

patient group most commonly involved with poisoning?

deliberate self harm with substances that are easy to get
decreases with age from adolescents

281

which substance is associated with the highest mortality in terms of poising?

opioids

282

contraindications for use of charcoal in poisoning?

Absent bowel sounds (ileus)
Impaired gag reflex
Unsafe swallow

283

common things that charcoal is ineffective against?

alcohols
iron
cyanide
hydrocarbons

284

antidote for paracetamol and mech?

acetylecystine

glutathione repleter

285

antidote for opioids? and mech

naloxone- specific antagonist

286

antidote for methanol / ethylene glycol? mech

ethanol

specific antagonist

287

how much paracetamol is worrying?

12g

288

what is the dangerous metabolite in paracetamol OD?

NAPQI

289

complication of acetylecystine?

anaphylactoid reaction (not immune mediated)

290

symptoms of salicylate poisoning?

Dizziness
Sweating
Tinnitus
Vomiting
Hyperventilation
Agitation
Delirium

291

metabolic abnormalities in aspirin OD?

metabolic acidosis - salicylate ACID
respiratory alkalosis - resp. centre stimulation
hypoglycaemia
hypokalaemia

292

Ix for aspirin OD?

Ix the metabolic abnormalites (ABG, glucose, U&Es)
plasma salicylate conc

293

clinical features of iron toxicity and how they progress

• Early (0-6 hours):
o Nausea and vomiting
o Abdo pain
o Diarrhoea [bloody]
o Massive GI fluid loss
• Delayed (2-72 hours):
o Black offensive stools
o Drowsiness/coma
o Fits
o Circulatory collapse
• Late (2-4 days):
o Acute liver necrosis
o Renal Failure
• Very late (2-5 weeks):
o Gastric strictures

294

when must iron be measured to establish toxicity?

4 hrs after ingestion

295

what is used to chelate iron?

Desferrioxamine

296

why is charcoal NOT normally indicated in bnzo OD?

increased risk of aspiration

297

what is the antidote for bnzos and when is it used?

Flumenazil

best in bnzo naïve patients
can precipitate withdrawal in regular users

298

presentation and mech of action of organophosphates?

Muscarinic effects – bronchospasm – may lead to airway compromise
Nicotinic effects – weakness and paralysis of respiratory muscles
Cardiac rhythm abnormalities


inhibition of acetylcholinesterase -> build up of ACh -> overstimulation of nicotinic and muscarinic receptors

299

in what time frame does activated charcoal need to be given in?

1 hr

300

what is the antidote for benzos? mech of action

flumazinil
anti-cholenergic

301

Mx of anapylactoid reaction?

stop infusion
give H2 antagonist
restart infusion

302

what is in codydramol?

paracetamol
dihydrocodeine

303

t1/2 of naloxone?

1hr - important thing is that this is SHORTER than opioids

304

what will an abg look like in paracetamol OD?

metabolic acidosis

305

what will an abg look like in opioid OD?

resp. acidosis

306

severe aspirin poisoing ->?

vasodilation, hypoventilation, delirium

as well as the symptoms of less severe OD: tinnitus, dizzy, sweating