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Flashcards in NPS Deck (38):
1

Carrie Westcott (38 years old, female, married with children, bank employee) was diagnosed with bipolar disorder type I by a psychiatrist last year after she experienced two depressive episodes and a manic episode.
Her husband brought her to the ED worried that she had become increasingly irritable, and stopped eating and drinking in the last 2 days.

lithium s/e:
- short term: gastrointestinal discomfort with nausea and diarrhoea, vertigo and muscle weakness
- long term: weight gain, fine tremor, fatigue, thirst, polyuria, cardiovascular and thyroid problems, leucocytosis, bluish discoloration/pain in fingers and toes, pseudotumor cerebri and rarely angioneurotic oedema

Non-pharm mx:
- De-escalation of acute episode
- Psychosocial strategies emphasising adherence to medication
- Education and support of patient, family and carers
- Interpersonal and social rhythm therapy
- Cognitive Behavioural Therapy (CBT)
- Addressing substance/alcohol abuse and medical illnesses
- MDT
- medicolegal considerations

Pharm:
- acute: antipsychotic +/- benzo
- long term: lithium (valproate secondline), but start now because slow acting

2

A 75-year-old man, Mr Robert Fisk, living independently with his wife, presents to ED distressed with acute onset shortness of breath which woke him from sleep. He has a history of previously well-controlled heart failure secondary to a dilated cardiomyopathy. Further questioning reveals symptoms consistent with paroxysmal nocturnal dyspnoea and 4-pillow orthopnoea over the previous two nights. He does not have a history of ischaemic heart disease. His only other health problem is osteoarthritis. Vital signs include a blood pressure of 130/80 and pulse rate of 108/minute in a regular rhythm. His other examination findings were consistent with acute pulmonary oedema.

Non-pharm mx
- PPO(ND)
- fluid and Na restriction - long term

Pharm
- N: initially sublingual, then IV
- D:
- don't forget VTE prophylaxis
- cease PDE-5i, beta blockers, NSAIDs etc

3

15 year old male was brought in by his mother presenting with general "unwellness", reduced energy, sleep disturbance, moodiness, fighting with peers and family, arguing, and needing prompting to complete school work.

2y later apprentice motor mechanic and his mother is fearful that he may lose his apprenticeship. He is binge drinking with mates most weeks. He denies using any other illicit substances. He often oversleeps in the morning and seems to have little interest in activities. He has had a few "sickies" from work and he is missing soccer training more often than not, he was previously devoted to his sport.

Non-pharm:
- CBT
- Psychoeducation and supportive counselling
- Drug & Alcohol counselling
- Nutrition
- Other complementary and lifestyle interventions
- psychiatrist referral not necessary rn

Pharm: if refractory
- fluoxetine: limited evidence for other SSRIs, none for TCAs

S/E
- stomach upset and loose bowel actions, headaches, agitation, loss of libido or impacts on sexual function, restlessness and sleeping or sedation problems. Weight gain or loss may result in the consideration of a change of medication.
- SS: changes to mental state (confusion, hypomania, agitation) and myoclonus/clonus, hyperreflexia, tremor and poor coordination.

4

Mrs Connie Anderson is 42 years old and was admitted this morning with increasing tiredness and breathlessness without chest pain over several weeks. She has had heavy periods but no history of acute bleeding. On admission Mrs Anderson was noted to be pale without signs of heart failure.
Results of blood tests were:
Microcytic hypochromic anaemia.
Haemoglobin (Hb) 60 g/L (NR: 115–165)
Serum iron 6 micromol/L (NR: 14–32)
Serum ferritin 3 micrograms/L (NR: 25–155)
Serum folate and B12 pending.

Non-pharm
- blood transfusion if necessary
- consider cause - improve diet, consider ceasing drugs that cause bleeding, increase metabolism (eg phenytoin for folate), antagonise effect (eg methotrexate for folate)....

Pharm
- supplementation

Drug interactions
- Fe: drugs that increase gastric pH eg antacids

5

Maria Pappas is a 62-year-old Greek lady with persistent degenerative arthritic pain mainly from known lumbar spine disease with osteoarthritis. An X-ray in 2002 showed significant spondylolisthesis of her lumbar spine and bilateral lumbar facet joint arthritis. She has other widespread osteoarthritic changes, especially in her temporomandibular joint and her hands. This interferes with one of her favourite social occupations; playing cards. All other medical conditions except for her persistent pain are well controlled. She suffers greatly from constant pain in the joints which is aggravated by motion, and she is finding it increasingly difficult to mobilise. For the last four years her osteoarthritic pain has been controlled with regular paracetamol (1 g, four times daily) and once daily dosing of celecoxib (200 mg, once daily) (both initiated by her GP). Maria presents today complaining that her back pain is quite severe even with regular use of paracetamol and celecoxib. Joint pain and stiffness begin to occur after long periods of inactivity, such as when sitting for long journeys or watching a two-hour television show. The pain is moderately severe even at rest or with very little movement. She asks if you can prescribe something 'stronger'.
Her recent bone mineral density (BMD) score was -2.7 T-score units. A T-score of -2.5 or less (that is -2.6, -2.7, and so on) is indicative of osteoporosis. Again an X-ray is undertaken and excludes any fractures.

multi-modal, multidisplinary approach using both non-drug interventions and pharmacotherapy. Realistic goals need to be set and health professionals should engage patients in a conversation about their expectations in the light of these goals. A cure may not be likely but coping with less pain is realistic in this case.

Non-pharm
- Patient education about pain and its management
- Massage
- Heat and cold applications
- Exercise
- Cognitive behaviour therapy (CBT)
- Transcutaneous electrical nerve stimulation (TENS)
- Weight loss
- Physiotherapy
- Occupational therapy

Pharm
- paracetamol
- NSAID: low dose for minimal duration - avoid regular use
- opioids: consider potential risks before starting
- others eg neuropathic, TCA, ketamine etc

6

86-year old Polish woman, who has presented with exacerbation of chronic obstructive pulmonary disease and is now recovering well. You note that her pulse is irregular and the ECG confirms AF at a rate of 67 beats per minute. You review her previous admissions and note that going back to 2 years previously, she has always been in AF during her admissions, and the patient's general practitioner (also Polish) confirms that she has had an irregular pulse when she has seen him as well. You make the diagnosis of rate controlled permanent non-valvular AF. You perform an echocardiogram which shows a large left atrium, but it is otherwise normal. You speak to your senior colleague who suggests that you consider stroke risk reduction.

Non-pharm options - specialist decision:
- Electrical cardioversion
- AV node ablation and pacemaker insertion
- Radiofrequency catheter ablation of arrhythmogenic foci in atria, usually found around pulmonary veins
- Surgical maze procedure
- Internal atrial defibrillators
- Obliteration of left atrial appendage.

Pharm
- aspirin for if CHADS2VASc 1 ONLY IF ANTI-COAG CONTRAINDICATED
- anticoag if 2 or more
- warfarin fine
- in community, risks of double anticoagulation greater than risks of not bridging warfarin
- NOACs need dose reduction in elderly and renal impairment

Ongoing
- regular Hb and INR monitoring

7

Mrs Roberta Fernando was treated for acute pulmonary oedema in ED. Now she has been admitted to the medical ward under your care.
Her usual medications include:
hydrochlorothiazide (25 mg daily)
perindopril arginine (2.5 mg daily)
atorvastatin (40 mg in the morning)
aspirin (100 mg daily)
On admission, her potassium is 4.2 mmol/L, creatinine 96 micromol/L. Your task now is to optimise the treatment of chronic heart failure.
There are 2 NPS modules on heart failure. The first focuses on acute heart failure and the treatment of pulmonary oedema. This second module examines the treatment of chronic heart failure.

Non-pharm
- look for and remove precipitating factors eg infections, ischaemia, arrhythmias, lack of compliance (diet, meds)=> vax, CVD risk optimisation, diagnosis and treatment of depression
- cease/avoid drugs that can precipitate heart failure: steroids, NSAIDs, verapamil
- salt and water restriction
- regular exercise
- daily weights
- smoking cessation
- remain active, DON'T REST UNNECESSARILY

Pharm
- CCF (carvedilol, perindopril, frusemide)
- can add spironolactone
- ARBs if ACEi not tolerated; dig if firstline drugs don't work

8

Mrs Umaga has been brought in by ambulance because she has been getting more short of breath over the past 3-4 days, and her normally non-productive cough has worsened. She is coughing more frequently and she is bringing up yellow sputum.
On admission she was not breathless at rest but had mild central cyanosis. Heart rate was 96 (sinus rhythm). Jugular vein pressure was not elevated, she had widespread wheezing sounds but no basal crepitations. Temperature was 37.0˚C. Her partial pressure of carbon dioxide (paCO2) was 47 mmHg and partial pressure of oxygen (paO2) was 52 mmHg with oxygen saturation (SaO2) 85%, haemoglobin 142 g/L, creatinine 0.09 mmol/L, sodium 139 mmol/L, potassium 3.8 mmol/L, bicarbonate 20 mmol/L.
There was no evidence of consolidation or heart failure on her admission chest radiograph.
Her admission medications are: salbutamol 200 micrograms by metered-dose inhaler (MDI) as required, tiotropium 18 micrograms daily, diltiazem (controlled release) 240 mg once daily, hydrochlorothiazide 25 mg daily, and paracetamol as required.

Non-pharm
- O2
- physio
LONG TERM
- pulm rehab: gradually increasing exercise
- support smoking cessation
- vax

Pharm
- SABA 2-6hrly, SAMA 6hrly (spacer reduces s/e, but nebulised fine)
- oral CS
- abx: amox/doxy
- nicotine for smoking cessation lol

9

Mr Grant is 77 years old and lives alone. He was admitted 24 hours ago with pneumonia which is being treated with antibiotics. He has responded well to the initial treatment and we won't consider this aspect of the case further. You are rung at midnight by the ward nurse. She says that the patient is not sleeping, is confused, restless and very noisy.
On examination he is disorientated, inattentive, tremulous and appears to be having visual hallucinations. His pulse rate is 106 beats per minute and he is sweating with a temperature of 38.4 °C.
Admission notes refer to a past history of heavy drinking and smoking.
On admission his gamma glutamine transpeptidase (GGT) is 240 units/L (normal range 0–60) and his mean corpuscular volume (MCV) 107 fL (normal range 80–100). Serum creatinine level is 180 micromol/L electrolytes are normal.

Non pharm
- Move him to a quiet room and dim the lighting
- Initiate an alcohol withdrawal chart
- Give him IV fluids

Pharm
- thiamine
- diazepam - IV stat, then PO (secondline: antipsych ie haloperidol; thirdline: betablocker)

*olanzepine is not good antipsych here because long time to onset and long half life make it difficult to titrate the dose to effect

10

Mrs Pitt is 82 years old and was admitted at 10 pm with shortness of breath due to an exacerbation of her chronic heart failure. You are called to see her at 3 am because she is wide awake, disorientated, confused and trying to climb out of bed. She is disturbing other patients and requiring intensive nursing time.
You note that before coming to hospital she was on regular once daily treatment with digoxin 125 microgram, sertraline 50 mg, chlorthalidone 12.5 mg and an ACE inhibitor. One week prior to admission indapamide 2.5 mg daily was added to her regimen to treat shortness of breath with crackles in her lungs.
All the above medications are still charted and in the Emergency Department she was slightly cyanosed and still short of breath and given frusemide 120 mg. On admission, her serum sodium was 116 mmol/L, potassium 4.3 mmol/L and creatinine 250 micromol/L. Examination revealed a raised jugular vein pressure and loud widespread basal crackles. Her oxygen saturation is 85. Her temperature is 36.7 °C and her pulse is 76 beats per minute.

Non-pharm
- Transfer her to a quiet area
- Ask her daughter to sit with her mother
- Check whether she has a full bladder
- Giving oxygen?
- Restrict oral and IV fluids

Pharm
- haloperidol (need an antipsych that works fast and is rapidly metabolised to it doesn't accumulate - so better for maintenance control)
- DON'T USE benzos - excess sedation and even resp failure in elderly patients

11

Mrs Amy Teague a 71 year old lady, diagnosed with type 2 diabetes 8 years ago, presents for a routine checkup with you.

Non-pharm
- Encourage weight loss
- healthy eating plan
- Recommend a reduction in consumption of alcohol
- Encourage smoking cessation
- Start intensive exercise
- Increase physical activity
- Monitor for complications of diabetes

Pharm
- metformin
- add another agent (usually sulfonylurea)
- add insulin (long acting) - target fasting BSL 6-8
- MDT: don't forget podiatry and dental

S/E
- metformin: GI, lactic acidosis
- exenatide: GI, pancreatitis, renal failure
- SGLT2 inhibitor: dehydration, UTIs, genital infections

12

Mr Smith, a 56-year-old truck driver, is referred to you after his blood pressure (BP) was recorded at 165/105 mmHg at a work site health check. He is asymptomatic.
Mr Smith had been diagnosed with asthma a few years before, for which he uses a salbutamol metered-dose inhaler, obtained over the counter from his chemist. He continues to smoke 15 cigarettes/day. Much of his diet comprises 'fast food' purchased at the roadside during his 65-hour long working weeks. He drinks up to 6-8 cans of mid-strength beer/day and is centrally overweight (BMI 29 kg/m2) with a waist circumference of 100 cm.

Symptoms of secondary hypertension: haematuria/nocturia (renal disease), flushing/tremor/palpitations (phaeo), claudication (could be CoA), hx of pressor intake

Non-pharm
- weight reduction
- reduced salt
- increase fruit and veg, omega-3 fish oils
- reduced alcohol
- increase PA

Pharm
- Firstline are ACEi(/ARB), CCB, thiazide diuretic (if >65yo)
- start low
- add another agent if not well controlled; check other factors eg compliance, lifestyle factors, ?secondary cause

Aim
- 125/75 IF >1g proteinuria/day

Other consideration
- beta blockers: contrai in asthma; consider if past MI
- thiazide: increased risk new-onset DM
- ACEi: cough - dose realted
- alpha blocker: postural hypotension

13

Insomnia

Non-drug
- Sleep hygiene
- Sleep restriction: only go to bed however long you normally actually sleep before the time you wake up -> periodically reassess, gradually increasing time
- Stimulus control therapy
- Relaxation therapy
- Paradoxical intention
- CBT

14

Ric Burke is a 49-year-old IT consultant who has come to see you as he is concerned that he is at risk of a heart attack. Ric has type 2 diabetes, diagnosed two years ago, which is well controlled. He has a family history of type 2 diabetes and his father, a long-term smoker, died recently of a heart attack at age 73. There is no other significant family history.
Ric has 6 or 7 alcoholic drinks per week and smokes 10 cigarettes a day (he has tried to quit a number of times without success). Ric's only exercise is his weekly social game of squash, and his lunch often consists of take-away meals. Ric takes extended release metformin 1000 mg in the evening and over-the-counter aspirin 100 mg in the morning. On examination his waist circumference is 100 cm, blood pressure 130/82 mmHg, resting pulse 75 beats per minute, with regular rhythm.
Ric's total cholesterol is 6.3 mmol/L, HDL cholesterol 1.8 mmol/L, LDL cholesterol 3.9 mmol/L and triglycerides 1.4 mmol/L. HbA1C is 6.7%. Renal function, liver function tests and full blood count are all within normal ranges. Microalbuminuria is not detected.

Assess risk
- low <10%

Non-pharm
- SNAP
- weight reduction: waist circumference 94cm or less

Pharm
- statin
- then consider adding ezetimibe, cholestyramine (bile acid binding resin), fibrate (esp if TAG high)

15

Mrs Roberta Fernando was treated for acute pulmonary oedema in ED. Now she has been admitted to the medical ward under your care.
Her usual medications include:
hydrochlorothiazide (25 mg daily)
perindopril arginine (2.5 mg daily)
atorvastatin (40 mg in the morning)
aspirin (100 mg daily)
On admission, her potassium is 4.2 mmol/L, creatinine 96 micromol/L. Your task now is to optimise the treatment of chronic heart failure.
There are 2 NPS modules on heart failure. The first focuses on acute heart failure and the treatment of pulmonary oedema. This second module examines the treatment of chronic heart failure.

Non-pharm
- look for and remove precipitating factors eg infections, ischaemia, arrhythmias, lack of compliance (diet, meds)=> vax, CVD risk optimisation, diagnosis and treatment of depression
- cease/avoid drugs that can precipitate heart failure: steroids, NSAIDs, verapamil
- salt and water restriction
- regular exercise
- daily weights
- smoking cessation
- remain active, DON'T REST UNNECESSARILY

Pharm
- CCF (carvedilol, perindopril, frusemide)
- can add spironolactone
- ARBs if ACEi not tolerated; dig if firstline drugs don't work

16

Mrs Umaga has been brought in by ambulance because she has been getting more short of breath over the past 3-4 days, and her normally non-productive cough has worsened. She is coughing more frequently and she is bringing up yellow sputum.
On admission she was not breathless at rest but had mild central cyanosis. Heart rate was 96 (sinus rhythm). Jugular vein pressure was not elevated, she had widespread wheezing sounds but no basal crepitations. Temperature was 37.0˚C. Her partial pressure of carbon dioxide (paCO2) was 47 mmHg and partial pressure of oxygen (paO2) was 52 mmHg with oxygen saturation (SaO2) 85%, haemoglobin 142 g/L, creatinine 0.09 mmol/L, sodium 139 mmol/L, potassium 3.8 mmol/L, bicarbonate 20 mmol/L.
There was no evidence of consolidation or heart failure on her admission chest radiograph.
Her admission medications are: salbutamol 200 micrograms by metered-dose inhaler (MDI) as required, tiotropium 18 micrograms daily, diltiazem (controlled release) 240 mg once daily, hydrochlorothiazide 25 mg daily, and paracetamol as required.

Non-pharm
- O2
- physio
LONG TERM
- pulm rehab: gradually increasing exercise
- support smoking cessation
- vax

Pharm
- SABA 2-6hrly, SAMA 6hrly (spacer reduces s/e, but nebulised fine)
- oral CS
- abx: amox/doxy
- nicotine for smoking cessation lol

17

Mr Grant is 77 years old and lives alone. He was admitted 24 hours ago with pneumonia which is being treated with antibiotics. He has responded well to the initial treatment and we won't consider this aspect of the case further. You are rung at midnight by the ward nurse. She says that the patient is not sleeping, is confused, restless and very noisy.
On examination he is disorientated, inattentive, tremulous and appears to be having visual hallucinations. His pulse rate is 106 beats per minute and he is sweating with a temperature of 38.4 °C.
Admission notes refer to a past history of heavy drinking and smoking.
On admission his gamma glutamine transpeptidase (GGT) is 240 units/L (normal range 0–60) and his mean corpuscular volume (MCV) 107 fL (normal range 80–100). Serum creatinine level is 180 micromol/L electrolytes are normal.

Non pharm
- Move him to a quiet room and dim the lighting
- Initiate an alcohol withdrawal chart
- Give him IV fluids

Pharm
- thiamine
- diazepam - IV stat, then PO (secondline: antipsych ie haloperidol; thirdline: betablocker)

*olanzepine is not good antipsych here because long time to onset and long half life make it difficult to titrate the dose to effect

18

Mrs Pitt is 82 years old and was admitted at 10 pm with shortness of breath due to an exacerbation of her chronic heart failure. You are called to see her at 3 am because she is wide awake, disorientated, confused and trying to climb out of bed. She is disturbing other patients and requiring intensive nursing time.
You note that before coming to hospital she was on regular once daily treatment with digoxin 125 microgram, sertraline 50 mg, chlorthalidone 12.5 mg and an ACE inhibitor. One week prior to admission indapamide 2.5 mg daily was added to her regimen to treat shortness of breath with crackles in her lungs.
All the above medications are still charted and in the Emergency Department she was slightly cyanosed and still short of breath and given frusemide 120 mg. On admission, her serum sodium was 116 mmol/L, potassium 4.3 mmol/L and creatinine 250 micromol/L. Examination revealed a raised jugular vein pressure and loud widespread basal crackles. Her oxygen saturation is 85. Her temperature is 36.7 °C and her pulse is 76 beats per minute.

Non-pharm
- Transfer her to a quiet area
- Ask her daughter to sit with her mother
- Check whether she has a full bladder
- Giving oxygen?
- Restrict oral and IV fluids

Pharm
- haloperidol (need an antipsych that works fast and is rapidly metabolised to it doesn't accumulate - so better for maintenance control)
- DON'T USE benzos - excess sedation and even resp failure in elderly patients

19

Mrs Amy Teague a 71 year old lady, diagnosed with type 2 diabetes 8 years ago, presents for a routine checkup with you.

Non-pharm
- Encourage weight loss
- healthy eating plan
- Recommend a reduction in consumption of alcohol
- Encourage smoking cessation
- Start intensive exercise
- Increase physical activity
- Monitor for complications of diabetes

Pharm
- metformin
- add another agent (usually sulfonylurea)
- add insulin (long acting) - target fasting BSL 6-8
- MDT: don't forget podiatry and dental

S/E
- metformin: GI, lactic acidosis
- exenatide: GI, pancreatitis, renal failure
- SGLT2 inhibitor: dehydration, UTIs, genital infections

20

Mr Smith, a 56-year-old truck driver, is referred to you after his blood pressure (BP) was recorded at 165/105 mmHg at a work site health check. He is asymptomatic.
Mr Smith had been diagnosed with asthma a few years before, for which he uses a salbutamol metered-dose inhaler, obtained over the counter from his chemist. He continues to smoke 15 cigarettes/day. Much of his diet comprises 'fast food' purchased at the roadside during his 65-hour long working weeks. He drinks up to 6-8 cans of mid-strength beer/day and is centrally overweight (BMI 29 kg/m2) with a waist circumference of 100 cm.

Symptoms of secondary hypertension: haematuria/nocturia (renal disease), flushing/tremor/palpitations (phaeo), claudication (could be CoA), hx of pressor intake

Non-pharm
- weight reduction
- reduced salt
- increase fruit and veg, omega-3 fish oils
- reduced alcohol
- increase PA

Pharm
- Firstline are ACEi(/ARB), CCB, thiazide diuretic (if >65yo)
- start low
- add another agent if not well controlled; check other factors eg compliance, lifestyle factors, ?secondary cause

Aim
- 125/75 IF >1g proteinuria/day

Other consideration
- beta blockers: contrai in asthma; consider if past MI
- thiazide: increased risk new-onset DM
- ACEi: cough - dose realted
- alpha blocker: postural hypotension

21

Insomnia

Non-drug
- Sleep hygiene
- Sleep restriction: only go to bed however long you normally actually sleep before the time you wake up -> periodically reassess, gradually increasing time
- Stimulus control therapy
- Relaxation therapy
- Paradoxical intention
- CBT

22

Ric Burke is a 49-year-old IT consultant who has come to see you as he is concerned that he is at risk of a heart attack. Ric has type 2 diabetes, diagnosed two years ago, which is well controlled. He has a family history of type 2 diabetes and his father, a long-term smoker, died recently of a heart attack at age 73. There is no other significant family history.
Ric has 6 or 7 alcoholic drinks per week and smokes 10 cigarettes a day (he has tried to quit a number of times without success). Ric's only exercise is his weekly social game of squash, and his lunch often consists of take-away meals. Ric takes extended release metformin 1000 mg in the evening and over-the-counter aspirin 100 mg in the morning. On examination his waist circumference is 100 cm, blood pressure 130/82 mmHg, resting pulse 75 beats per minute, with regular rhythm.
Ric's total cholesterol is 6.3 mmol/L, HDL cholesterol 1.8 mmol/L, LDL cholesterol 3.9 mmol/L and triglycerides 1.4 mmol/L. HbA1C is 6.7%. Renal function, liver function tests and full blood count are all within normal ranges. Microalbuminuria is not detected.

Assess risk
- low <10%

Non-pharm
- SNAP
- weight reduction: waist circumference 94cm or less

Pharm
- statin
- then consider adding ezetimibe, cholestyramine (bile acid binding resin), fibrate (esp if TAG high)

23

Winston Blake is a 64-year-old artist who has come to see you for worsening back pain.

Non-pharm
- patient information and education
- CBT
- manual therapy: manipulation, mobilisation, massage
- exercise
- relaxation techniques
- TENS
- self-management

Pharm
- NSAIDs for breakthrough pain
- Morphine is firstline opioid (/oxycodone/bupe if morphine contraindicated)

Other considerations
- codeine is too short acting for long term pain relief
- fentanyl is too strong for opioid naive patients
- tramadol has same a/e and less analgesia

24

Ms Sasha Walcott, a 35-year-old woman presents requesting a script for Panadeine Forte (paracetamol 500 mg and codeine 30 mg) for her migraine. She reports receiving a script from a general practitioner for 20 tablets on Saturday morning. However, she has taken all the medication and reports that she took her last 2 tablets of Panadeine Forte several hours ago. She is now complaining of worsening bitemporal bandlike headache, sweating, abdominal pain and diarrhoea. She reports that she has used Panadeine Forte for headache for 4 years, initially taking 2 tablets once or twice per week, but over time this has increased and she now takes 10–12 per day. She attends a number of general practitioners for scripts, and for the last 18 months has supplemented her Panadeine Forte use with ibuprofen/codeine combinations which she buys as an over-the-counter (OTC) medication. Initially she took 4–6 of the ibuprofen/codeine combination, but now a packet of 48 tablets will last 2–3 days. This evening, she went to three pharmacies to try and buy more but they were all closed. She reports that she had an endoscopy 1 month ago for epigastric discomfort which identified 2 pre-pyloric erosions, and was commenced on omeprazole. At that time, the gastroenterologist advised her to avoid NSAIDs, but she did not disclose her ibuprofen/codeine use to him. In addition, at that time, her haemoglobin was normal.
On examination Sasha is afebrile, and there are no signs of meningism. Her pupils are dilated at 6 cm bilaterally, but otherwise neurological examination is normal. Heart rate is 102 beats per minute, blood pressure is 130/90 mmHg. Her abdomen is soft, with some tenderness in the epigastric region, but no guarding. Bowel sounds are present and rectal examination is normal with no meleana. She has rhinorrhoea.

Non-pharm
- counselling

Pharm
- OST with dialy supervised admin: methadone, buprenorphine
- considerations: if bupe is given to someone with high levels of an agonist -> withdrawal; bupe has less tox; in liver disease start low
- no evidence for naltrexone

25

Mrs Julianna Morelli (23 years old) walks into A&E because her GP's surgery is closed. After taking a history and doing an examination you note the following:
She is very uncomfortable with dysuria and frequency of micturition.
She is afebrile and has had no rigors.
There is no abdominal or loin pain or tenderness.
Her urine is turbid, positive for both nitrites and leukocytes but does not contain blood.
She gives a history of a skin rash after receiving an antibiotic some years ago. The antibiotic was a penicillin.
You put some urine aside for microbiology in the morning.
You make a confident diagnosis of an uncomplicated lower urinary tract infection. On the basis of local prevalence patterns you suspect the infection is caused by E.coli.

Non-pharm:
- Increase her fluid intake.
- cranberry juice might work prophylactically but doesn't work as treatment

Pharm
- trim (RULE OUT PREGNANCY), the others

26

Mrs. Hope is an 87 year old woman admitted with worsening renal function, vomiting, 2nd degree heart block and a recent history of falls. She has a background of cardiac failure, hypertension, non insulin dependent diabetes mellitus, renal impairment, osteoarthritis of the left knee and recent onset dyspepsia. She lives alone and has poor eyesight secondary to diabetic retinopathy. Mrs Hope is taking the following medications on admission:
digoxin 0.25 mg, one nocte
frusemide 40 mg, one mane
slow-K (potassium chloride), 600mg, 2 bd
verapamil 80 mg, one tds
metformin 1 g, one tds
diclofenac 50 mg, one tds
diazepam 10 mg, one tds
nitrazepam 10 mg, one nocte
ranitidine 300 mg, one daily
Serum creatinine previously stable at 0.12 mmol / L (normal range 0.05 – 0.1 mmoL / L).
On admission, creatinine 0.23 mol / L. Mrs. Hope weighs 50 kg. Her calculated creatinine clearance has therefore decreased from 22 ml / min to 12 ml / min.
Sodium 140 mmoL / L (135 –145), potassium 4.1 mmoL / L (3.2 – 4.5).
Digoxin concentration 3.1 micrograms / L (0.8 – 2.0).

Non-pharm
-rehydration
-walking stick to reduce stress on L knee
-lifestyle measures for diabetes
-Na restriction for BP
-lifestyle measures for insomnia

Pharm
- as required for conditions - review what firstline treatment is now and whether any lifstyle measures can improve conditions

*consider what potassium-retaining mechanisms in place (eg ACEi, renal impairment) before replacing
*avoid negative inotropes in heart failure
*metformin contraindicated in GFR < 30
*temaz is shorter acting
*dig can cause heart block

*kidney cleared drugs: frusemide, dig, metformin
*liver cleared: diaz, verapamil

*nephrotoxic: ACEi, NSAID, dehydration

27

Catheter-associated UTI

Non-pharm
- minimise time catheterised
- change catheter if infection and catheter required

Pharm
- asymptomatic bacteriuria and pyria are common -> NO TREATMENT
- investigate only systemic infection
- empirical for sepsis is IV amp and gent - 10-14 days
- should be guided by culture if not emergency

28

Surgical prophylaxis

Non-pharm
- good surgical technique including haemostasis
- skin antisepsis
- avoid shaving patient preoperatively

Pharm indications
- significant risk of infection (eg colonic resection) or where postop infection would be real srs
- 30-60min preop
- for 24hr postop


- cephazolin if no known MRSA risk factors
- vanc if worried about MRSA

29

Jack is an 18-month old boy who is brought to the emergency department at night. Jack's mother says that he's had a cough and runny nose for a few days. He has also been vomiting and not feeding very well. Today his mother noticed that he also has fever and seems to be a bit more miserable. He woke up from sleep crying and she just can't settle him. She states that she thinks "he probably needs antibiotics again". Examination reveals fever of 39.5 °C and a miserable child who is very difficult to handle. He has a moist cough and muco-purulent nasal discharge. Examination of his ears shows fluid in the middle ear on one side with a diffusely dull and red tympanic membrane.

Non-pharm
- avoid abx and review again in 24-48hr
- Frequent small volume of oral clear fluids
- Saline nose drops

Pharm
- panadol
- consider amox if high risk (Indigenous, previous recurrent episodes, systemically unwell, very young)

30

An 18-year-old woman, Jeanne d'Arcy is brought in by ambulance after suffering a generalised seizure, the onset of which was witnessed by her mother. By the time she reaches the hospital she is rousable but drowsy. She has no focal neurological signs. She is afebrile and there appears to be no precipitating factors for this seizure. Her mother states that she had one previous fit 2 weeks ago. Her GP organised a CT head scan, and the results were normal. The GP arranged a referral to a neurologist but no treatment had been started. She describes no aura on either occasion. Her only medication is the combined oral contraceptive pill.

Non-pharm
- acute: Placing her in a safe position in the acute setting; consider emegency CT/MRI
- chronic: discuss and avoid precipitating factors (drugs, drug withdrawal, sleep deprivation, infections, fever, stress); advising not to drive (6 months), PREGNANCY CONSIDERATIONS

Pharm: after second seizure

S/E:
due to enzyme induction
- increase elimination of most other AED, OCP, warfarin, ART etc
- carbamazepine: SJS, induces its own metabolism
- lamotrigine: SJS
- valproate: sedation, dizziness, weight gain
- phenytoin: gum hypertrophy, hirsuitism, arrhythmias

31

Mr. Richard Chisholm, a 47 year old computer technician, is your first patient of the day. Richard is an existing patient of the practice, having attended only twice in the last 5 years. You have not seen him before today.
Richard states that for some time now, he has been thirsty more than is usual for him. His notes state that he is not on any regular medications, has no known allergies and his past medical history is of allergic rhinitis and sporting injuries.

Non-pharm
- SNAP
- education

Pharm
- metformin
- then add another agent
- then insulin

32

Mr Richard Chisholm, aged 50, attends for a routine follow up appointment for his type 2 diabetes diagnosed 3 years ago.
(T2D

Non-pharm
- SNAP
- Education
- SMBG
- ?bariatric surgery

Pharm
- consider triple therapy: metformin + sulfonylurea + something else (eg exenatide)
- consider insulin if triple therapy doesn't work for 6 months

33

Mrs Julianna Morelli (23 years old) walks into A&E because her GP's surgery is closed. After taking a history and doing an examination you note the following:
She is very uncomfortable with dysuria and frequency of micturition.
She is afebrile and has had no rigors.
There is no abdominal or loin pain or tenderness.
Her urine is turbid, positive for both nitrites and leukocytes but does not contain blood.
She gives a history of a skin rash after receiving an antibiotic some years ago. The antibiotic was a penicillin.
You put some urine aside for microbiology in the morning.
You make a confident diagnosis of an uncomplicated lower urinary tract infection. On the basis of local prevalence patterns you suspect the infection is caused by E.coli.

Non-pharm:
- Increase her fluid intake.
- cranberry juice might work prophylactically but doesn't work as treatment

Pharm
- trim (RULE OUT PREGNANCY), the others

34

Mr Johannes Kepler is a 69-year-old male who underwent a hemicolectomy for carcinoma of the descending colon. He has not yet received chemotherapy and is not neutropenic. He develops a fever and chills 3 days post-operatively. He is still nil-by-mouth and he is being maintained on intravenous fluids.
Routine surgical antibiotic prophylaxis was administered and consisted of single doses of cephazolin and metronidazole.
On questioning, he had no focal symptoms. Examination revealed a swinging fever between 37.0°C and 38.8°C for the last 12 hours, a pulse rate of 90–100 beats per minute, a BP of 130/75 mmHg (not changed from pre-operative), a clear chest, a non-tender abdomen except around the abdominal wound but with occasional bowel sounds. The wound itself looks clean, dry and non-inflamed. The peripheral intravenous cannula site was red and tender.

Non-pharm
- remove IV line
- maintain IV fluids

Pharm
- empirical bacteraemia is fluclox and gent - 14 days IV

35

Catheter-associated UTI

Non-pharm
- minimise time catheterised
- change catheter if infection and catheter required

Pharm
- asymptomatic bacteriuria and pyria are common -> NO TREATMENT
- investigate only systemic infection
- empirical is IV amp and gent - 10-14 days

36

Surgical prophylaxis

Non-pharm

Pharm indications
- significant risk of infection (eg colonic resection) or where postop infection would be real srs
- 30-60min preop
- for 24hr postop


- cephazolin if no known MRSA risk factors
- vanc if worried about MRSA

37

The provisional diagnosis is sepsis secondary to acute pyelonephritis.

IV abx usually only upto 48 hrs

38

ACS

Non-pharm
- SNAP
- chest pain action plan
- pharm review
- cardiac rehab

Pharm
- MONA Hep C
- BAS (within 24-48 hours)