Passing the PSA Flashcards
(149 cards)
1
Q
Drugs to stop before surgery
A
I LACK OP insulin lithium anticoagulants, antiplatelets COCP/HRT K sparing diuretics oral hypoglycaemics perindopril and ACE inhibitors
2
Q
When do you need to stop the OCP and HRT before surgery?
A
4 weeks
3
Q
before surgery: when do you stop lithium?
A
day before
4
Q
When do you stop potassium sparing diuretics and ACE inhibitors before surgery?
A
day of surgery
5
Q
What are the 9 things we have to think about for safe prescribing?
A
- Is it the correct patient?
- Do they have any allergies?
- Did you sign the front of the chart
- Consider any contraindications for the drug I am prescribing
- consider the route
- consider the need for IV fluids
- consider the need for thromboprophylaxis
- need for antiemetic
- consider the need for pain relief
6
Q
What does the mnemonic PReSCRIBER stand for?
A
Patient details Reaction (allergies) Sign the front of chart check for Contraindications to each drug check Route for each drug prescribe IV fluids if needed prescribe Blood clot prophylaxis if needed prescribe antiEmetics if needed prescribe pain Relief if needed
7
Q
What two commonly prescribed drugs both have penicillin in them?
A
co-amoxiclav and Tazocin
8
Q
What are the four classes of drugs you must know the contraindications for?
A
- drugs that increase the bleeding risk
- for steriods
- NSAIDS
- antihypertensives
9
Q
What are the contraindications for anticoagulation?
A
bleeding
suspicion that they could be bleeding
ischemic stroke (because could bleed into stroke)
Erythromycin (enzyme inducer) increase the PT and INR
10
Q
What are the SE of steroids?
A
eyes= cataracts, glaucoma
face- moon like facies cushingoid appearance
cardiovascular- heart failure
skin and bones- osteoporosis and skin thinning and infection
endocrine= diabetes
11
Q
NSAID contraindications
A
No urine Systolic dysfunction Asthma indigestion Dyscrasia clotting abnormality
12
Q
What are the SE of ACE inhibitors
A
dry cough, hyperkalemia,
13
Q
SE of Beta blockers and CA channel blockers
A
hypotension
14
Q
Should Beta blockers be prescribed in asthmatics?
A
nope
15
Q
SE of calcium channel blockers
A
perpheral oedema and flushing
16
Q
diuretics can cause?
A
renal failure
17
Q
What two drugs can cuase gout
A
thiazide diuretics and frusemide
18
Q
Spirolactatone can cause
A
cause gyncomastia
19
Q
Iv potassium what is the maximum infusion rate?
A
10 mmol/hour
20
Q
What are the two situations fluids are prescribed?
A
replacement
maintenance
21
Q
Which fluid are you going to give patients?
A
0.9% normal saline
22
Q
when would you give 5% dextrose to a patient
A
hypernatremic or hypoglycemia
23
Q
What would you give your patient for fluid resus if the patient has ascites?
A
human albumin solution
24
Q
In fluid resuscitation how do you know how much fluid to give?
A
HR, BP, urine output
500 ml bolus 0.9%
if heart failure 250 ml
25
If the patient is only oligouric how do you give the fluid?
give 1 litre over 2-4 hours than reassess the patient
26
How can you predict the fluid deficit?
reduced urine output will be decreased
500ml
reduced UO plus tachycardia 1 litre of fluid
plus shock- greater than 2 L fluid depletion
27
How do you prescribe maintenance fluids?
general rule: elderly 2 L
| normal 3L
28
What do you give for daily maintenance?
1 salty 2 sweet
| 1 litre normal saline and 2 litres of 5% dex
29
With a normal potassium level what is the daily requirement for the patient K?
40mmol per day (20 mmol per bag)
30
How fast can you give maintenance fluids?
So to calculate this all you have to do is take the
amount of fluid you need to give and divide from 24 hours.
So if the patient is elderly then you are going to give 2L over 24 hours therefore 1 bag every 12 hours
if needing to give three litres than it is 24 divided by 3 is 8 hourly
31
What should you do before prescribing fluids?
check the patient’s U&Es
check that the patient is not fluid overloaded
check that the patient’s bladder is not palpable.
32
Most patients will be prescribed low molecular weight heparin why wouldn’t you?
bleeding or risk of bleeding
33
When should compression stockings not be prescribed?
in PVD, in celulitis
in skin grafting
mixed arterial and venous disease
acute stroke
34
If the patient is nauseated what do you prescribe?
cyclizine 50mg 8 hourly IV
35
What is the adverse Se of cyclizine?
fluid retention
36
When would you not rep scribe cyclizine?
in heart failure so metoclopramide 10 mg 8 hourly
37
If the patient is not nauseated what anti-emetic would you use?
PRN anti-emetic
cyclizine 50mg every 8 hours
metoclopramide 50 mg to 8 hourly
38
when would you aviod metclopromide?
patients with parkinson’s
| young women—-> dyskinesia - acute systolic reaction
39
If the patient is in no pain, but the nurse asks you to prescribe paracetamol
PRN 1 g up to 6 hourly oral
40
mild pain chart up dose of paracetamol?
regular meds
1 g 6 hourly
PRN
codeine 30 mg up to 6 hourly
41
severe pain prescribe analgesia
co-codamol 30/500 2 tablets every 6 hours
PRN morphine sulphate 10 mg up to 6 hourly oral
42
What is the first line treatment for neuropathic pain?
amitriptyline (10 mg oral nightly)
pregabalin 75 mg 12 hourly
duloxetine 60 mg OD
43
Remember what does co-codamol have in it?
30/500
30 mg codeine
500 mg paracetamol
44
What is the max daily dose of paracetamol?
4 g
45
What antibiotic should not be given with methotrexate?
trimethoprim as it is also a folic acid antagonist
46
What antihypertensive can cause peripheral oedema?
calcium channel blocker
47
If you have a normal ejection fraction and peripheral oedema what do you need to consider before putting the patient on frusemide?
drug induced by calcium channel blocker
48
What are the causes for hyponatremia
dehydration
drips
drugs
diabetes insipidus
49
what are the causes of neutrophillia?
bacterial infection
tissue damage (inflammation, infarct, malignancy)
steriods
50
what are the causes of low neutrophils
viral infection
chemotherapy
clozapine
carbimazole (antithyroid)
51
what a re the causes fro thrombocytopenia?
```
reduced production:
infection
drugs (penicillamine- RA)
myeloma myelodysplasia, myelofibrosis
increased destruction:
heparin
hypersplenism
DIC
ITP
heamolytic uremic syndrome
TTP
```
52
high platelets
```
reactive:
bleeding
tissue damage (infection/inflammation/ malignancy)
post-splenectomy
primary:
myeloproliferative disorders
```
53
If the patient is hypovolemic what are the causes of hyponatremia?
fluid loss (D&V)
addisons
diuretics
54
What is the patient is euvolemic what are the causes of hyponatremia?
SIADH
psychogenic polydipsia
hypothyriodism
55
hypervolemic but hyponatremic what is the cause?
```
heart failure
liver failure
renal failure
nutritional failure
thyriod failure (hypothyriodism)
```
56
What are the cause of syndrome of inappropriate ADH secretion?
small cell lung ca
infection
abcess
drugs
57
what are the cause of hypokalaemia?
drugs (loop or thiazides)
inadequate intake or intestinal loss
renal tubular acidosis
endocrine (sunshine’s and conns)
58
What are the causes of hyperkalemia?
drugs potassium sparing diuretics and ACE inh
renal failure
artefactual
diabetic ketoacidosis
59
What does raised urea indicate?
kidney injury or upper GI heamorrhage
60
What are the cause of AKI?
prerenal- dehydration, shock, sepsis, blood loss, renal artery stenosis
```
intrinsic- ischemia (acute tubular necrosis) nephrotoxic antibiotics gent vanc, tetracyclines
contrast
gout
glomerulonephritis
cholesterol emboli
post renal
lumen- stone or slough papilla
wall tumour or fibrosis
external - BPH, lymphadenopathy, aneurysm
```
61
If you want to determine whether or not the cause fo the renal injury is pre or post what can you do?
multiply the urea by 10 if it exceeds the creatinine than it is prerenal
62
If the patient has a raised creatinine but a relatively normal urea what can you do to differentiate between intrinsic renal and postrenal?
intrinsic renal
bladder and hydronephrosis not palpable
post renal may be
63
What do you look at in the LFTs to determine hepatocyte injury?
bilirubin
ALT
AST ALP
64
What do you look at in the LFTs to determine synthetic function?
albumin
| coagulation profile
65
What can also raise the ALP
```
fracture
liver damage
cancer
pagers disease
pregnancy
osteomalacia
surgery
```
66
How do you interpret and change levothyroxine depending on the results on the tests?
TSH less than .5 decrease dose
if it is in the sweet spot of .5-5 then stay the same
if TSH is greater than 5 ask about complicance and then increase dose
67
what are the cause of pre hepatic LFT derangement
heamolysis
| gilbert and crigler najjar
68
intrahepatic
```
fatty liver
hepatitis
cirrhosis
malignancy
metabolic wilson/ hemochromatosis
heart failure
```
69
post hepatic failure
lumen: gallstone,
wall tumour
extrinsic pressure pancreatic or gastric ca
70
What are some drugs that can cause post hepatic obstruction?
flucloxacillin co amoxiclav
nitrofurantoin
steroids
sulphonylureas
71
primary hypothyriodism TFT look like?
T4 down
| TSH up
72
secondary hypothyroid
T4 down
| TSH down
73
primary hyperthyroidism
t4 up TSH down
74
secondary hyperthyroidism TFT
T4 up
| TSH up
75
What are the causes of primary hypothyroidism
hashimotos
| drug induced
76
causes of secondary hypothyroidism
pituitary tumour or damage
77
primary hyperthyroidism
graves’ disease
toxic nodular goitre
drug induced
78
secondary hyperparathryoidism
pit tumour
79
What a re the ABCDE signs of pulmonary oedema?
```
alveolar oedema
kerley B lines
cardiomegaly
Diversion of blood to the upper lobes
pleural effusion
```
80
When interpreting blood gases it is important to follow this routine?
check the inspired oxygen concentration
approximate the FIO2 take % oxygen minus 10 this should be at least the patients PaO2
check for respiratory failure type 1 type 2
check the acid base status
think about the causes
81
What is the causes of respiratory alkalosis
rapid breathing- disease or anxiety
82
respiratory acidosis causes
slow or shallow breathing
| COPD and less commonly nueromuscular failure or restrictive wall abnormalities
83
What are the causes of metabolic acidosis
lactic acidosis
DKa
renal failure
ethanol methanol glycol intoxication
84
What are the causes of metabolic alkalosis
vomiting diuretics and conns syndromes
85
What are the most common drugs prescribed that have a narrow therapeutic index?
```
digoxin
theophylline
lithium
phenytoin
and vancomycin and gentamicin
```
86
What are the features of toxicity for digoxin?
confusion nausea and vomiting and visual halos and arrhythmias
87
lithium toxicity
```
early tremor
tiredness
arrhythmias
seizures
coma
renal failure
diabetes insipidus
```
88
Phenytoin toxicity
```
gum hyperplasia
ataxia
nystagmus
peripheral neuropathy
teratogenicity
```
89
gentamicin
ototoxicity and nephrotoxicity
90
vancomycin toxicity
ototoxicty and nephrotoxicity
91
What is paracetamol normally metabolisms by?
liver
92
How does paracetamol overdosing happen
limited hepatic stores of glutathione are quickly depleted
there is a toxic accumulation of NAPQI
causes acute liver damage
93
What is the protocol for Warfarin based on INR
less than 6 reduce dose
6-8 omit warfarin for 2 days then reduce
greater than 8 omit and give 1-5 mg oral warfarin
94
Target INR for most patients
| target for heart valves
2. 5 INR
| 3. 5 INR heart valves
95
What do you do for a major bleed if the patient is on warfarin
stop warfarin
give 5-10 mg IV vitamin K
give prothrombin complex
96
How does Ibuprophen contribute to renal injury?
it decreases blood flow to the kidneys by inhibiting prostaglandin (vasodilator) mimics pre renal failure causing increase in urea and creatinine and potassium
97
What antihypertensive drug can cause hyperkalemia?
ACE inh
98
What commonly prescribed antibiotic can cause warfarin levels in the blood to increase?
erythromyocin
99
Treatment for neutropenic sepsis
pip taz with gent
100
What antihypertensive drug class can cause hyponatremia?
ca channel blocker
101
What medication commonly given in uti should not be given in pregnancy?
trimethoprim
102
in an acute setting what should you give for CCF
furosemide 40 mg iv
103
name another loop diuretic besides frusemide
bumetanide
104
what is the commonly used ca channel blocker in af
diltiazem
105
what drug is good for neuropathic pain relief?
amitriptyline 10 mg nightly
106
What is the management plan for STEMI
```
ABC and O2
aspirin 300mg
morphine 5-10 mg IV with metoclopramide 10 mg IV
GTN spray
primary PCI or thrombolysis
Beta blocker atenolol 5 mg
```
107
Non- ST elevation MI
ABC and O2
aspirin 300 mg
morphine 5-10 mg IV with metoclopromide 10 mg IV
GTN spray
clopidogrel 300 mg and LMWH
Beta blocker atenolol 5 mg (unless LVF or asthma)
108
Left ventricular failure
```
ABCs and o2
sit the patient up
morphine 5-10 mg IV with metclopromide 10 mg IV
GTN spray
frusemide 40-80 mg IV
```
109
What are the elements that are needed to managing a STEMI?
ABC and resus
history examination investigations confirming dx
aspirin dose 300mg oral
morphine 5-10mg IV with meclopramide 10 mg IV
GTN spray
primary PCI or thrombolysis
B blocker * atenolol 5 mg oral
110
What are the elements of treating a NSTEMI?
```
ABCS and resus
dx NSTEMI
asprin 300 mg oral
morphine 5-10 mg IV with metclopromide 10 mg IV
GTN
clopidogrel 300 mg oral and LMWH
enoxaparin 1 mg/kg BD SC
```
111
WHat are your management steps with acute left ventricular failure?
ABCs and resus
confirm the dx
sit the patient
morphine 5 mg IV with metoclopramide 10 mg IV
GTN spray *only if the patient’s bp is greater than 100 systolic
furosemide 40-80 mg IV
if inaquete response isosorbide dinitrate infusion.
plus or minus ?CPAP= pulmonary oedema
112
The patient is tachycardic what is your plan?
```
first determine sick or unsick? shock syncope myocardial infarction heart failure
if so DC shock 3 times
amiodarone 300 gm IV over 10-20 min
r/p amiodarone 900 mg over 24 hours
————-
stable qrs
narrow regular
vagal adenosine 6 mg then 12
not workin sh atrial flutter? b block
if irregular
control rate with block or diltiazem
hf? digoxin
—————
wide qrs
irregular sh
regular—- amiodarone 300 mg iv
```
113
Anaphylaxis pathway
```
ABCs and resus
confirm and focused hx and exam
remove cause ASAP
iv access bloods fbc u&e mast cell tryptase immed after, 1 harm 6-24 h later
adrenaline 500 micrograms of 1:1000 IM
chlorphenamine 10 mg slow iv
hydrocortisone 200 mg IV
asthma treat wheeze 5 mg salbutamol
```
114
Asthma pathway
```
ABC
100% O2
salbutamol 5 mg NEB
Hydrocortisone 100 mg IV (if severe)
or Prednisalone 40-50 mg if moderate
Ipratropium bromide 500 micrograms NEB
theophylline (life threatening)
```
115
Treatment for pneumonia
```
ABCs
high flow O2
antibiotics according to the CURB 65 score and if onset was in or out of hospital
paracetamol for pain relief
if low BP or tachycardic fluid resus
```
116
treatment for pulmonary embolism
```
ABCs
sit up unless low BP
high flow O2
Morphine 5-10 mg IV
metoclopromide 10 mg IV
LMWH tinzaparin 175 units per kg SC daily
if low BP IV gelofusine
noradrenaline
thrombolysis
```
117
What is the management for a GI bleed?
```
ABCS
cannula
catheter (fluid monitoring)
crystalloid
cross match 6 units
correct clotting abnormalities
endoscopy
stop culprit drugs like NSAIDS aspirin warfarin and heparin
call the surgeons if severe
```
118
What are you looking for the in the clotting screen if a patient is bleeding? When would you replace?
platelets if less than 50 x 10^9
| PT/APPT greater than 1.5 times the upper limit of normal
119
What is the treatment of bacterial meningitis?
ABCs
high flow O2
IV fluid
dexamethasone IV unless sevely immunocompromised
LP (plus or minus CT head)
2 g cefotaxime IV plus Vanc (using GAPP)
consider ITU
120
What is the treatment pathway for status epilepticus?
ABCs
put patient into the left lateral decubitus position with O2
check the glucose
take blood s and establish IV access
5-20 minutes:
lorazepam 4 mg IV over 2 min repeat at 10 minutes if no effect
inform the anaesthesist
Phenytoin infusion 20 mg/ kg IV at less than 50 mg per minute
intubation with propofol
121
Management of stroke
ABCs
blood glucose and CT head to exclude heamorrhage
if aged less than 80 and onset is less than 4.5 hrs thrombolysis
Aspirin 300 mg Oral for 14 days
transfer to the stroke unit
122
What is the treatment for hyperglycemia
```
ABCs
IV fluids
1 L stat then 1 L over 1 hours
then 2 hours then 4 hours then 8 hours
sliding scale insulin
hunt for trigger (infection, MI, missed insulin)
monitor BM K and pH
```
123
What is he management of AKI
```
ABCs
cannula and catheter fluid monitoring
IV fluids and 500 ml stat then 1 L hourly
hunt for cause and complications
monitor U&Es and fluid compliance
```
124
what is the mgx for acute poisoning?
Abcs
cannula and catheter strict fluid balance
supportive measures
correct E- disturbance
reduce absorption (less than 1 hour- gastric lavage or charcoal)
increase elimination
psychiatric management
125
What medication do you give for paracetamol overdose?
N acetyl cysteine (paracetamol level at 4 hours is over the line on treatment)
126
What do you take for opiate poisoning?
Naloxone
127
What so you take for benzo overdose?
Flumazenil
128
Treatment for Heart failure
```
treat the underlying cause
smoking cessation
cardiac rehab
B blockers and ACE inh
EF less than 35% can add aldosterone anatongonist
```
129
What is the treatment for Parkinson Disease
levodopa and carbidopa
life style effecting
non lifestyle affecting
dopamine agonists (ropinirole)
monoamine oxidase inhibitors (selegiline)
On and off effect may need to add MAO B inh COMT inh, and dopamine agonists
130
Epilepsy management
```
generalised- Na valproate
absence- Na valproate
myoclonic - Na val
tonic NA val
focal- Carbamazepine or lamotrigine
```
131
What are the SE of lamotrigine
rash, rarely steven johnson syndrome
132
What is the SE of carbamazepine
rash, dysarthria, ataxia, nystagmus, hyponatremia
133
What are the SE of phenytoin?
ataxia, P neuropathy, gum hyperplasia hepatotoxicty
134
Na valproate
tremor teratogencity weight gain
135
When do you not give a laxative?
When there are evidence of obstruction
absolute constipation no flatus
abdominal distension
136
What is one of the side effects of Carbimazole?
neutropenia
137
What are the SE of carbamazepine?
This is a treatment for neuropathic pain. can cause neutropenia
138
What is Donepezil licensed for?
mild to moderate Alzheimer’s disease
139
What is me mantiene licensed for?
severe alzheimer disease
140
What are two drugs not to be prescribed in Parkinson’s
metoclopromide and Haloperidol because they are dopamine agonists
141
Should you prescribe an ACE inhibitor in pregnancy?
No it is tetratogenic especially in the first trimester
| switc to labetalol
142
What are some common SE of tamoxifen?
increased risk of endometrial ca
messes with Warfarin leading to increased INR
hot flushes
increased risk of VTE
143
What time of the day should Gliclazide should be taken?
morning with breakfast
144
What medications should never be used with Methotrexate?
folate antagonists such as trimethoprim (which is also the reason this drug should not be used in pregnancy)
and co-trimoxazole
145
how do you look after patients on Warfarin?
initially weekly blood tests and then once stable blood tests monthly
146
What are the side effects of ACE inh
hyperkalemia
cough
monitor for CKI every 1-2 weeks do U&Es
147
What SE of SSRIs do you need to warn the patient of?
dry mouth
suicidal ideation
photosentivity
symptoms of serotonin syndrome agaitation, temperature, hallucinations
148
What is the weird thing you have to tell patients on bisphosphonates?
Tablet needs to be swallowed with a full glass of water and remain upright for 30 minutes afterwards.
Bisphosphonates are a once weekly preparation.
149
What creatinine clearance is deemed unsafe for patients who are going to be put on Gent?
less than 20 ml/min
